Provider Demographics
NPI:1518425313
Name:SMITH, KELLIE DORTON
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:DORTON
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:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-1770
Mailing Address - Country:US
Mailing Address - Phone:276-594-1197
Mailing Address - Fax:276-452-1974
Practice Address - Street 1:1401 VETRAN MEMORIAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251
Practice Address - Country:US
Practice Address - Phone:276-594-1197
Practice Address - Fax:276-452-1974
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)