Provider Demographics
NPI:1679322994
Name:SMITH, KATRINA WYNN (FNP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:WYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17806 TIDE LINE DR
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8273
Mailing Address - Country:US
Mailing Address - Phone:828-713-2352
Mailing Address - Fax:
Practice Address - Street 1:17806 TIDE LINE DR
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8273
Practice Address - Country:US
Practice Address - Phone:828-713-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029203363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner