Provider Demographics
NPI:1851689467
Name:SMITH, KELLY O (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:O
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:47 JOLLEY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3092
Mailing Address - Country:US
Mailing Address - Phone:860-243-3020
Mailing Address - Fax:860-243-3002
Practice Address - Street 1:47 JOLLEY DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3092
Practice Address - Country:US
Practice Address - Phone:860-243-3020
Practice Address - Fax:860-243-3002
Is Sole Proprietor?:No
Enumeration Date:2011-07-16
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT002588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant