Provider Demographics
NPI:1053631887
Name:SMITH, KRISTIE A (PT)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-5011
Mailing Address - Country:US
Mailing Address - Phone:515-471-9720
Mailing Address - Fax:515-471-9725
Practice Address - Street 1:50 E HICKMAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-5011
Practice Address - Country:US
Practice Address - Phone:515-216-2999
Practice Address - Fax:515-216-2990
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1053631887Medicaid
IAP01308570OtherRR MEDICARE
IA719260238Medicare PIN