Provider Demographics
NPI:1588297360
Name:SMITH, CARLA KNIGHTON
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:KNIGHTON
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 N 400 E STE B
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1756
Mailing Address - Country:US
Mailing Address - Phone:435-881-0973
Mailing Address - Fax:435-514-1333
Practice Address - Street 1:2380 N 400 E STE B
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1756
Practice Address - Country:US
Practice Address - Phone:435-881-0973
Practice Address - Fax:435-514-1333
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4921902-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty