Provider Demographics
NPI:1619107976
Name:SMITH, CONNIE (APRN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-5328
Mailing Address - Country:US
Mailing Address - Phone:859-404-7686
Mailing Address - Fax:859-274-0785
Practice Address - Street 1:209 NORTH MAYSVILLE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353
Practice Address - Country:US
Practice Address - Phone:859-404-7686
Practice Address - Fax:859-274-0785
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12028306OtherCAQH