Healthcare Provider Details

I. General information

NPI: 1972173698
Provider Name (Legal Business Name): KYLE EVERETT SMITH DNP-CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 COLLEGE DR
MOUNT CARMEL IL
62863-2638
US

IV. Provider business mailing address

9274 N 1400 BLVD
MOUNT CARMEL IL
62863-4598
US

V. Phone/Fax

Practice location:
  • Phone: 618-262-8621
  • Fax:
Mailing address:
  • Phone: 812-664-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209023445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: