Provider Demographics
NPI:1326035148
Name:SMITH, KELLI PUGH (AUD)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:PUGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 ENTERPRISE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6249
Mailing Address - Country:US
Mailing Address - Phone:757-825-2500
Mailing Address - Fax:757-825-2521
Practice Address - Street 1:901 ENTERPRISE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6249
Practice Address - Country:US
Practice Address - Phone:757-825-2500
Practice Address - Fax:757-825-2521
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAAUD003627231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA236186432AMedicaid