Healthcare Provider Details

I. General information

NPI: 1982378139
Provider Name (Legal Business Name): KIMBERLY LYNNE SMITH RN BSN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 E WILLIS RD
GILBERT AZ
85297-2089
US

IV. Provider business mailing address

2107 E WILLIS RD
GILBERT AZ
85297-2089
US

V. Phone/Fax

Practice location:
  • Phone: 480-586-8541
  • Fax:
Mailing address:
  • Phone: 480-586-8541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number227329
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-303739
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: