Provider Demographics
NPI:1104548981
Name:SMITH, KACEY
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21253 S BUCKHILL RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-9066
Mailing Address - Country:US
Mailing Address - Phone:386-299-8080
Mailing Address - Fax:
Practice Address - Street 1:300 S MAIN ST UNIT 2
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-4542
Practice Address - Country:US
Practice Address - Phone:386-299-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11021601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner