Provider Demographics
NPI:1699407965
Name:SMITH, KOURTNEY DANIELLE (PRSS)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:DANIELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6189 ROSALIND RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2324
Mailing Address - Country:US
Mailing Address - Phone:304-948-5004
Mailing Address - Fax:
Practice Address - Street 1:6189 ROSALIND RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2324
Practice Address - Country:US
Practice Address - Phone:304-948-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist