Provider Demographics
NPI:1497998983
Name:KHOURY-SMITH, KRISTY DAWN (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:DAWN
Last Name:KHOURY-SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:DAWN
Other - Last Name:KHOURY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:4725 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4603
Mailing Address - Country:US
Mailing Address - Phone:954-492-5753
Mailing Address - Fax:
Practice Address - Street 1:4725 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-492-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500606885Medicaid
OR146609Medicare PIN
WA8539439Medicaid