Basic Information
Provider Information | |||||||||
NPI: | 1831196419 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | KIM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TENEYCK | ||||||||
OtherFirstName: | KIM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | C.N.P. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1050 ISAAC STREETS DR | ||||||||
Address2: | SUITE 137 | ||||||||
City: | OREGON | ||||||||
State: | OH | ||||||||
PostalCode: | 436163291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196984505 | ||||||||
FaxNumber: | 4196983806 | ||||||||
Practice Location | |||||||||
Address1: | 5700 MONROE ST UNIT 310 | ||||||||
Address2: |   | ||||||||
City: | SYLVANIA | ||||||||
State: | OH | ||||||||
PostalCode: | 435602768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198240356 | ||||||||
FaxNumber: | 4198246193 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2005 | ||||||||
LastUpdateDate: | 11/02/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP07074 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 2347517 | 05 | OH |   | MEDICAID |