Provider Demographics
NPI:1831196419
Name:SMITH, KIM (CNP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:TENEYCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:1050 ISAAC STREETS DR
Mailing Address - Street 2:SUITE 137
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3291
Mailing Address - Country:US
Mailing Address - Phone:419-698-4505
Mailing Address - Fax:419-698-3806
Practice Address - Street 1:5700 MONROE ST UNIT 310
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2768
Practice Address - Country:US
Practice Address - Phone:419-824-0356
Practice Address - Fax:419-824-6193
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2347517Medicaid
OHNP28841Medicare PIN