Provider Demographics
NPI:1508083189
Name:SMITH, KELLY WAYNE (NP FNP-PP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:NP FNP-PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BAY CLINIC, LLP
Mailing Address - Street 2:1750 THOMPSON RD
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-269-0333
Mailing Address - Fax:
Practice Address - Street 1:BAY CLINIC, LLP
Practice Address - Street 2:1750 THOMPSON RD
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-269-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP01122Medicare UPIN