Provider Demographics
NPI:1700261591
Name:KELLEY, ELIZABETH ANNE SMITH (CRNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE SMITH
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 GATEWAY DR
Mailing Address - Street 2:#C
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-1500
Mailing Address - Country:US
Mailing Address - Phone:334-741-0075
Mailing Address - Fax:
Practice Address - Street 1:2214 GATEWAY DR
Practice Address - Street 2:#C
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-1500
Practice Address - Country:US
Practice Address - Phone:334-741-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-131673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL185931Medicaid
AL102I504371Medicare PIN