Healthcare Provider Details

I. General information

NPI: 1104459718
Provider Name (Legal Business Name): KATIE GRACE SMYTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 04/11/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-8621
US

IV. Provider business mailing address

770 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-8621
US

V. Phone/Fax

Practice location:
  • Phone: 616-290-1876
  • Fax:
Mailing address:
  • Phone: 616-290-1876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009773
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: