=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871880278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN SUZAN STREET D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2011
-----------------------------------------------------
Last Update Date | 11/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7001 ROGERS AVE STE 502
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-484-5901
-----------------------------------------------------
Fax | 479-484-0778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776084
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-484-5901
-----------------------------------------------------
Fax | 479-484-0778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | E-9166
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | T-2492
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------