Provider Demographics
NPI:1467916437
Name:SMITH, KIMBERLY ALICIA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ALICIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:ALICIA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:6216 SETON HILLS LN
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6080
Mailing Address - Country:US
Mailing Address - Phone:443-421-8589
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD STE A308
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3135
Practice Address - Country:US
Practice Address - Phone:301-808-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR175031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine