MEDICARE: MRS. KATHLENA M SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	11008569	FL

General Provider Information

NPI Number	:	1356926646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLENA M SMITH

Provider Business Mailing Address
First Line	:	145 BID A WEE LN
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-2762
Country	:	US
Telephone Number	:	334-655-6608
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 BID A WEE LN
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-2762
Country	:	US
Telephone Number	:	334-655-6608
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2021
Last Update Date	:	03/17/2021

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