Healthcare Provider Details

I. General information

NPI: 1740965714
Provider Name (Legal Business Name): KATIE SMITH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 10/02/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PALM AVE
JACKSONVILLE FL
32207-8432
US

IV. Provider business mailing address

1301 PALM AVE
JACKSONVILLE FL
32207-8432
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN9363808
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11028956
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: