Provider Demographics
NPI:1205500345
Name:SMOOT, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:SMOOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8626 W HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53228-1748
Mailing Address - Country:US
Mailing Address - Phone:414-739-3806
Mailing Address - Fax:
Practice Address - Street 1:8626 W HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53228-1748
Practice Address - Country:US
Practice Address - Phone:414-739-3806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver