Provider Demographics
NPI:1750375911
Name:KENNEDY SMITH, COLLEEN M (CRNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:KENNEDY SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12510 PROSPERITY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1663
Mailing Address - Country:US
Mailing Address - Phone:240-485-5200
Mailing Address - Fax:301-625-6906
Practice Address - Street 1:520 N ELAM AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1127
Practice Address - Country:US
Practice Address - Phone:336-547-1745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC319217363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ56991Medicare UPIN
MD492062Medicare PIN