Healthcare Provider Details

I. General information

NPI: 1134593601
Provider Name (Legal Business Name): KIMBERLY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2015
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E OLENTANGY ST
POWELL OH
43065-9069
US

IV. Provider business mailing address

120 E OLENTANGY ST
POWELL OH
43065-9069
US

V. Phone/Fax

Practice location:
  • Phone: 614-898-1211
  • Fax: 614-961-1096
Mailing address:
  • Phone: 614-898-1211
  • Fax: 614-961-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: