Provider Demographics
NPI:1639694276
Name:SMITH, KELLY AMANDA (MSN, RN, CPNP-PC/AC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:AMANDA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC/AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:2040 MARKET ST APT 1104
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-3369
Mailing Address - Country:US
Mailing Address - Phone:585-739-0235
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017721363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care