Healthcare Provider Details

I. General information

NPI: 1063835130
Provider Name (Legal Business Name): MISTY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY KEETON CRNA

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 10/11/2025
Certification Date: 10/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 DIXMYTH AVE
CINCINNATI OH
45220-2475
US

IV. Provider business mailing address

PO BOX 632572
CINCINNATI OH
45263-2572
US

V. Phone/Fax

Practice location:
  • Phone: 513-862-2432
  • Fax:
Mailing address:
  • Phone: 513-520-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3008488
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: