Healthcare Provider Details

I. General information

NPI: 1942203765
Provider Name (Legal Business Name): KENNETH E SMITH CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 BELMONT AVE STE 19B
YOUNGSTOWN OH
44505-1439
US

IV. Provider business mailing address

PO BOX 746071
ATLANTA GA
30374-6071
US

V. Phone/Fax

Practice location:
  • Phone: 330-222-4030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.05173
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: