Provider Demographics
NPI:1730634791
Name:SMYTH, KELLY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:SMYTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 N MOUNTAIN RD STE 207
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-4325
Mailing Address - Country:US
Mailing Address - Phone:860-696-2040
Mailing Address - Fax:860-696-2050
Practice Address - Street 1:183 N MOUNTAIN RD STE 207
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-4325
Practice Address - Country:US
Practice Address - Phone:860-696-2040
Practice Address - Fax:860-696-2050
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3654363AS0400X
IL085.006397363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.006397OtherIL PA LICENSE