Healthcare Provider Details

I. General information

NPI: 1942502786
Provider Name (Legal Business Name): KRISTINA SMITH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 E HICKORY AVE
CRESTVIEW FL
32536-2742
US

IV. Provider business mailing address

502 E HICKORY AVE
CRESTVIEW FL
32536-2742
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-1100
  • Fax: 850-683-0599
Mailing address:
  • Phone: 850-683-1100
  • Fax: 850-683-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-108545
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-108545
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11002474
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: