Provider Demographics
NPI:1528035078
Name:SMITH, KELLY J (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3731
Mailing Address - Country:US
Mailing Address - Phone:269-382-2500
Mailing Address - Fax:269-373-7478
Practice Address - Street 1:200 N PARK ST
Practice Address - Street 2:WEST MICHIGAN CANCER CENTER
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3731
Practice Address - Country:US
Practice Address - Phone:269-382-2500
Practice Address - Fax:269-373-7478
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704152480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4631966Medicaid
MI4631966Medicaid