Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 14817-24 | WI |
NPI | 1053955682 |
---|---|
Provider Name | Kayla Smith |
First Address | Appleton, WI 54914-6882 |
Second Address | Glendale, WI 53209-3852 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2019 |
Last Update Date | 06/11/2019 |