Provider Demographics
NPI:1063130227
Name:SMITH, KOLTER LEE (PMHNP-BD)
Entity type:Individual
Prefix:DR
First Name:KOLTER
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PMHNP-BD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 E WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-8850
Mailing Address - Country:US
Mailing Address - Phone:928-242-5716
Mailing Address - Fax:
Practice Address - Street 1:4107 E WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-8850
Practice Address - Country:US
Practice Address - Phone:928-242-5716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ279313363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health