Healthcare Provider Details

I. General information

NPI: 1376945261
Provider Name (Legal Business Name): KENNETH SMITH II DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

IV. Provider business mailing address

15301 WARREN SHINGLE RD BLDG 5700
BEALE AFB CA
95903-1905
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-4623
  • Fax:
Mailing address:
  • Phone: 530-634-4114
  • Fax: 530-634-4763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number63613
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: