Provider Demographics
NPI:1124746664
Name:SMITH, KOKEYSHA R (AG-ACNP)
Entity type:Individual
Prefix:
First Name:KOKEYSHA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 AUBURN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-4042
Mailing Address - Country:US
Mailing Address - Phone:817-614-1641
Mailing Address - Fax:
Practice Address - Street 1:8200 WALNUT HILL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4402
Practice Address - Country:US
Practice Address - Phone:214-345-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1091098363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care