Provider Demographics
NPI:1992109755
Name:SMITH, KATHLEEN W (APN)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:W
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10611 N SLEEPY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1121
Mailing Address - Country:US
Mailing Address - Phone:309-712-1363
Mailing Address - Fax:309-517-7476
Practice Address - Street 1:900 MAIN STREET SUITE 280
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-4688
Practice Address - Country:US
Practice Address - Phone:309-643-6118
Practice Address - Fax:309-517-7476
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209.012013363L00000X
IL209012013364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner