Healthcare Provider Details

I. General information

NPI: 1316306194
Provider Name (Legal Business Name): KERRI A SMITH ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

IV. Provider business mailing address

11155 DUNN RD STE 309
SAINT LOUIS MO
63136-6150
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-9100
  • Fax:
Mailing address:
  • Phone: 314-953-8799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016003059
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.024237
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: