Provider Demographics
NPI:1780757187
Name:SMITH, PETSY ANN (NP)
Entity type:Individual
Prefix:
First Name:PETSY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PETSY
Other - Middle Name:ANN ELIZABETH
Other - Last Name:KEPPLE- SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:451 CLARKSON AVE
Mailing Address - Street 2:KINGS COUNTY HOSPIYAL MEDICAL BOARD BOX 22
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2057
Mailing Address - Country:US
Mailing Address - Phone:917-771-8332
Mailing Address - Fax:
Practice Address - Street 1:24315 129TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1007
Practice Address - Country:US
Practice Address - Phone:718-245-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily