MEDICARE: MS. KRISTIN N SMITH ANP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN104595	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2005003310-21	OTHER	AZ	NURSE PRACTITIONER CERTIF

General Provider Information

NPI Number	:	1174598775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTIN N SMITH ANP

Provider Business Mailing Address
First Line	:	5303 W HACKAMORE DR
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85310-4418
Country	:	US
Telephone Number	:	623-266-2690
Fax Number	:	623-337-4224

Provider Business Practice Location Address
First Line	:	5303 W HACKAMORE DR
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85310-4418
Country	:	US
Telephone Number	:	623-266-2690
Fax Number	:	623-337-4224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	03/07/2023

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