Provider Demographics
NPI:1467919365
Name:KELLY SMITH, DIANNE (APRN)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:KELLY SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 409075
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9075
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-347-1426
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-864-0269
Practice Address - Fax:850-862-1163
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL1152616363LP0808X
OR202105184NP-PP363LP0808X
FLAPRN11009591363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health