Provider Demographics
NPI:1194068361
Name:SMALL, KATHRYN MAE (ACNP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MAE
Last Name:SMALL
Suffix:
Gender:
Credentials:ACNP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MAE
Other - Last Name:KOEBBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:3535 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1221
Mailing Address - Country:US
Mailing Address - Phone:937-395-6665
Mailing Address - Fax:937-395-6668
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-6665
Practice Address - Fax:937-395-6668
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14097363L00000X
OHAPRN.CNP.14097363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082730Medicaid
IN201199110Medicaid
IN201199110Medicaid
OH0082730Medicaid