Provider Demographics
NPI:1205151057
Name:SMITH PETERS, KATHLEEN M (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:SMITH PETERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-1022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1191 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-1022
Practice Address - Country:US
Practice Address - Phone:571-261-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165383363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health