Provider Demographics
NPI:1447572441
Name:SMITH, KATHRYN L (APN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 20
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1733
Practice Address - Country:US
Practice Address - Phone:260-266-2500
Practice Address - Fax:260-266-2514
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003192A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000819721OtherANTHEM BCBS
IN201025970Medicaid
IN000000819721OtherANTHEM BCBS