Healthcare Provider Details

I. General information

NPI: 1124746664
Provider Name (Legal Business Name): KOKEYSHA R SMITH AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 WALNUT HILL LN
DALLAS TX
75231-4402
US

IV. Provider business mailing address

4721 AUBURN RIDGE DR
FORT WORTH TX
76123-4042
US

V. Phone/Fax

Practice location:
  • Phone: 214-345-6789
  • Fax:
Mailing address:
  • Phone: 817-614-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1091098
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: