Provider Demographics
NPI:1700386588
Name:SMITH, KATHLEEN MARIE (RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14289 BURNT MLS
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-6791
Mailing Address - Country:US
Mailing Address - Phone:832-803-6208
Mailing Address - Fax:
Practice Address - Street 1:14289 BURNT MLS
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77318-6791
Practice Address - Country:US
Practice Address - Phone:832-803-6208
Practice Address - Fax:832-803-6208
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-18
Last Update Date:2018-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX836361163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse