Provider Demographics
NPI:1023379989
Name:KILLGORE-SMITH, KORTNEY KYLE (ARNP)
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:KYLE
Last Name:KILLGORE-SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 SOUTH THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328
Mailing Address - Country:US
Mailing Address - Phone:509-382-2531
Mailing Address - Fax:509-382-3205
Practice Address - Street 1:235 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAITSBURG
Practice Address - State:WA
Practice Address - Zip Code:99361
Practice Address - Country:US
Practice Address - Phone:509-337-6311
Practice Address - Fax:509-337-6011
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60281165363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8915859Medicare Oscar/Certification