Provider Demographics
NPI:1497344311
Name:SMITH, KAITLIN TERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:TERESA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 JACKSON ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6101
Mailing Address - Country:US
Mailing Address - Phone:716-982-7051
Mailing Address - Fax:
Practice Address - Street 1:475 PROSPECT AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4197
Practice Address - Country:US
Practice Address - Phone:973-325-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00689900207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program