Provider Demographics
NPI:1811978026
Name:SMITH, KATHERINE JOAN (ARNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JOAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:JOAN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:60 W GORE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1141
Mailing Address - Country:US
Mailing Address - Phone:407-423-1039
Mailing Address - Fax:407-425-2347
Practice Address - Street 1:60 W GORE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1141
Practice Address - Country:US
Practice Address - Phone:407-423-1039
Practice Address - Fax:407-425-2347
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2701012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306617700Medicaid
FL306617700Medicaid
P68681Medicare UPIN
FLE5186WMedicare PIN