Provider Demographics
NPI:1457960692
Name:SMITH, KOURTNI
Entity Type:Individual
Prefix:
First Name:KOURTNI
Middle Name:
Last Name:SMITH
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 1:11 BAMBOO TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26763-4515
Mailing Address - Country:US
Mailing Address - Phone:304-790-3077
Mailing Address - Fax:
Practice Address - Street 1:11 BAMBOO TRAIL LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:WV
Practice Address - Zip Code:26763-4515
Practice Address - Country:US
Practice Address - Phone:304-790-3077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant