Provider Demographics
NPI:1558740548
Name:KATHLEEN A SMERKO PMHNP-BC LLC
Entity Type:Organization
Organization Name:KATHLEEN A SMERKO PMHNP-BC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMERKO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PSY NP, BC
Authorized Official - Phone:602-235-9505
Mailing Address - Street 1:1121 E MISSOURI AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2723
Mailing Address - Country:US
Mailing Address - Phone:602-235-9506
Mailing Address - Fax:602-235-9506
Practice Address - Street 1:1121 E MISSOURI AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2723
Practice Address - Country:US
Practice Address - Phone:602-235-9506
Practice Address - Fax:602-235-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN071540363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
425240Medicare UPIN