Provider Demographics
NPI:1619310802
Name:GRUMMER-SMITH, KELLY RENAE (NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENAE
Last Name:GRUMMER-SMITH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:39 KENT RD STE 5
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1697
Practice Address - Country:US
Practice Address - Phone:229-353-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180155163WL0100X, 363LP0200X
CA545382163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant