Provider Demographics
NPI:1477025070
Name:SMITH, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:CUSHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36 WOTRING RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-9334
Mailing Address - Country:US
Mailing Address - Phone:724-825-1690
Mailing Address - Fax:
Practice Address - Street 1:575 COAL VALLEY RD STE 570
Practice Address - Street 2:
Practice Address - City:JEFFERSON HILLS
Practice Address - State:PA
Practice Address - Zip Code:15025-3729
Practice Address - Country:US
Practice Address - Phone:412-469-7660
Practice Address - Fax:412-469-7547
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PASP020243363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
14589600OtherCAQH
PA103746336Medicaid