Provider Demographics
NPI:1164955498
Name:SMITH, KELLY GHISLAINE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GHISLAINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E ARTESIA ST STE 330
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2922
Mailing Address - Country:US
Mailing Address - Phone:909-622-5654
Mailing Address - Fax:909-622-4914
Practice Address - Street 1:160 E ARTESIA ST STE 330
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2922
Practice Address - Country:US
Practice Address - Phone:909-622-5654
Practice Address - Fax:909-622-4914
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA172901207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program