Healthcare Provider Details

I. General information

NPI: 1962325415
Provider Name (Legal Business Name): KRISTEN SMITH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8773 MICMAC CT
POLK CITY FL
33868-6025
US

IV. Provider business mailing address

8773 MICMAC CT
POLK CITY FL
33868-6025
US

V. Phone/Fax

Practice location:
  • Phone: 734-652-9171
  • Fax:
Mailing address:
  • Phone: 734-652-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN SMITH
Title or Position: AGPC-NP
Credential: MSN, ARNP
Phone: 734-652-9171