Provider Demographics
NPI:1992371876
Name:SMOOT-REEVES, KELISHA
Entity Type:Individual
Prefix:
First Name:KELISHA
Middle Name:
Last Name:SMOOT-REEVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 DICKINSON ST APT 208
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-0005
Mailing Address - Country:US
Mailing Address - Phone:681-781-2348
Mailing Address - Fax:
Practice Address - Street 1:502 DICKINSON ST APT 208
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-0005
Practice Address - Country:US
Practice Address - Phone:681-781-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant