Provider Demographics
NPI:1568810018
Name:SMITH, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS
Mailing Address - Street 1:219 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1924
Mailing Address - Country:US
Mailing Address - Phone:402-375-5741
Mailing Address - Fax:402-375-3879
Practice Address - Street 1:219 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1924
Practice Address - Country:US
Practice Address - Phone:402-375-5741
Practice Address - Fax:402-375-3879
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470746990Medicaid