Provider Demographics
NPI:1760743918
Name:SMITH, KELLY PAYNE (RD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:PAYNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 DUNSTON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-4130
Mailing Address - Country:US
Mailing Address - Phone:719-237-7181
Mailing Address - Fax:
Practice Address - Street 1:9320 GRAND CORDERA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-7004
Practice Address - Country:US
Practice Address - Phone:719-344-2780
Practice Address - Fax:855-803-5480
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1036238133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered