Provider Demographics
NPI:1346720893
Name:SMITH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S KEARNY
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:TX
Mailing Address - Zip Code:79226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 S KEARNY
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:TX
Practice Address - Zip Code:79226
Practice Address - Country:US
Practice Address - Phone:806-664-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343698164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse