Provider Demographics
NPI:1518435122
Name:SMITH, KATELYN MARIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 JAKE ALEXANDER BLVD W STE 102
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1163
Practice Address - Country:US
Practice Address - Phone:704-637-1779
Practice Address - Fax:704-637-1121
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2025-11-05
Deactivation Date:2025-05-30
Deactivation Code:
Reactivation Date:2025-08-01
Provider Licenses
StateLicense IDTaxonomies
NC0010-15945363A00000X
MI5601009664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024181OtherNYS LICENSE