Provider Demographics
NPI:1235477894
Name:SMITH, KELLEY N (APRN)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:N
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:NEWTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:3300 WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-2902
Mailing Address - Country:US
Mailing Address - Phone:800-268-9160
Mailing Address - Fax:864-834-4966
Practice Address - Street 1:3300 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-2902
Practice Address - Country:US
Practice Address - Phone:864-268-9160
Practice Address - Fax:864-834-4966
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-14146363LF0000X
SC19696363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3506Medicaid