Provider Demographics
NPI:1154756393
Name:SMART, KATHLEEN R (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:SMART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-217-5700
Mailing Address - Fax:954-217-5704
Practice Address - Street 1:2300 N COMMERCE PKWY STE 103
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3255
Practice Address - Country:US
Practice Address - Phone:954-217-5700
Practice Address - Fax:954-217-5704
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9222846163WE0003X
FLAPRN9222846363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Single Specialty