Provider Demographics
NPI:1811750102
Name:SMITH, MILDRED KENNEDY (CRNP)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:KENNEDY
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26620 COTTON BAYOU DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE BEACH
Mailing Address - State:AL
Mailing Address - Zip Code:36561-3519
Mailing Address - Country:US
Mailing Address - Phone:334-430-6968
Mailing Address - Fax:
Practice Address - Street 1:310 GREENO RD S
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1905
Practice Address - Country:US
Practice Address - Phone:251-279-1605
Practice Address - Fax:251-279-1606
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-130918363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner