Healthcare Provider Details

I. General information

NPI: 1518435122
Provider Name (Legal Business Name): KATELYN MARIE SMITH PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date: 05/30/2025
Reactivation Date: 08/01/2025

III. Provider practice location address

1910 JAKE ALEXANDER BLVD W STE 102
SALISBURY NC
28147-1163
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-637-1779
  • Fax: 704-637-1121
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15945
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009664
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: