Provider Demographics
NPI:1811223464
Name:SMITH, KIM W (NP C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:W
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:W
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:5817 TUCKERTOWN LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1375
Mailing Address - Country:US
Mailing Address - Phone:336-339-1163
Mailing Address - Fax:
Practice Address - Street 1:5817 TUCKERTOWN LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1375
Practice Address - Country:US
Practice Address - Phone:336-339-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC132460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004844Medicaid