Provider Demographics
NPI:1194723130
Name:SMITH, KIM K (NP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-1353
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024165080363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015136910Medicaid
TN3900647Medicare PIN
VAS70542Medicare UPIN