Provider Demographics
NPI:1043598535
Name:SMITH, KYRA DIANE (APRN)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E SAN ANTONIO ST
Mailing Address - Street 2:SUITE 508E
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6050
Mailing Address - Country:US
Mailing Address - Phone:361-485-8585
Mailing Address - Fax:
Practice Address - Street 1:605 E SAN ANTONIO ST
Practice Address - Street 2:SUITE 508E
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6050
Practice Address - Country:US
Practice Address - Phone:361-575-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX700750363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX301720401Medicaid