Provider Demographics
NPI:1629461280
Name:KMIECIK, KATIE JO (FNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JO
Last Name:KMIECIK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:JO
Other - Last Name:GAFFNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:23865 FM 1314 RD
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-3727
Mailing Address - Country:US
Mailing Address - Phone:281-354-1815
Mailing Address - Fax:
Practice Address - Street 1:23865 FM 1314 RD
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-3727
Practice Address - Country:US
Practice Address - Phone:281-354-1815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1107048363LF0000X
NE111781363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily