Provider Demographics
NPI:1538514567
Name:SMITH, AUDREY RENEE (DO)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SAINT CHRISTOPHER DR STE 250
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7088
Mailing Address - Country:US
Mailing Address - Phone:606-836-3196
Mailing Address - Fax:606-836-2564
Practice Address - Street 1:1101 SAINT CHRISTOPHER DR STE 250
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7088
Practice Address - Country:US
Practice Address - Phone:606-836-3196
Practice Address - Fax:606-836-2564
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY04496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program