Provider Demographics
NPI:1346781564
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 1:2520 30TH AVE
Mailing Address - Street 2:FL 4
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2448
Mailing Address - Country:US
Mailing Address - Phone:718-808-7777
Mailing Address - Fax:
Practice Address - Street 1:4455 MACARTHUR BLVD NW
Practice Address - Street 2:APT 106
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2552
Practice Address - Country:US
Practice Address - Phone:413-219-1854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307972208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program