1205576022 NPI number — KIMBERLY STEVENSON SMITH FNP-C

Table of content: KIMBERLY STEVENSON SMITH FNP-C (NPI 1205576022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205576022 NPI number — KIMBERLY STEVENSON SMITH FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KIMBERLY
Provider Middle Name:
STEVENSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205576022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
295 CHIPETA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84108-1287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-558-8276
Provider Business Mailing Address Fax Number:
801-587-7539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
295 CHIPETA WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84108-4706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-588-8276
Provider Business Practice Location Address Fax Number:
801-587-7539
Provider Enumeration Date:
03/30/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11609135-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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