Healthcare Provider Details

I. General information

NPI: 1124519319
Provider Name (Legal Business Name): KRISTIN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 MEDICAL PLAZA LN
WHITESBURG KY
41858-7425
US

IV. Provider business mailing address

PO BOX 40
WHITESBURG KY
41858-0040
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-4871
  • Fax: 606-633-0883
Mailing address:
  • Phone: 606-633-4823
  • Fax: 606-633-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number3012073
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: