Provider Demographics
NPI:1316306194
Name:SMITH, KERRI A (ANP)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD STE 309
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6150
Mailing Address - Country:US
Mailing Address - Phone:314-953-8799
Mailing Address - Fax:
Practice Address - Street 1:1301 S KOKE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9252
Practice Address - Country:US
Practice Address - Phone:217-547-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016003059363LA2200X
IL209.024237363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health