Provider Demographics
NPI:1366039380
Name:SMITH-KRUEGER, KELLI RENE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:RENE
Last Name:SMITH-KRUEGER
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 1:460 SUTTER HILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:SUTTER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95685-4254
Mailing Address - Country:US
Mailing Address - Phone:209-267-8197
Mailing Address - Fax:
Practice Address - Street 1:460 SUTTER HILL RD STE B
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-4254
Practice Address - Country:US
Practice Address - Phone:209-267-8197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10274209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes209800000XAllopathic & Osteopathic PhysiciansLegal MedicineGroup - Multi-Specialty