Healthcare Provider Details

I. General information

NPI: 1023633427
Provider Name (Legal Business Name): KATHERINE ELLEN SMITH PNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE # 9100
SYRACUSE NY
13210-1687
US

IV. Provider business mailing address

100 ROCKFORD DR
SYRACUSE NY
13224-1828
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: