Provider Demographics
NPI:1942617980
Name:SMITH, KATHLEEN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 SOUNDVIEW AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-7128
Mailing Address - Country:US
Mailing Address - Phone:610-348-0546
Mailing Address - Fax:
Practice Address - Street 1:40 CROSS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4647
Practice Address - Country:US
Practice Address - Phone:203-845-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5783363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily