Provider Demographics
NPI:1174598775
Name:SMITH, KRISTIN N (ANP)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:N
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-4418
Mailing Address - Country:US
Mailing Address - Phone:623-266-2690
Mailing Address - Fax:623-337-4224
Practice Address - Street 1:5303 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-4418
Practice Address - Country:US
Practice Address - Phone:623-266-2690
Practice Address - Fax:623-337-4224
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN104595363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ949894Medicaid
AZ2005003310-21OtherNURSE PRACTITIONER CERTIF
AZMS1285926OtherDEA #
AZMS1285926OtherDEA #