Provider Demographics
NPI:1720081532
Name:SMART, KELLY M (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SMART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:608 NORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204
Mailing Address - Country:US
Mailing Address - Phone:615-695-1407
Mailing Address - Fax:615-695-1483
Practice Address - Street 1:141 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-552-4340
Practice Address - Fax:931-552-0999
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
TNPA1125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN620862316Medicaid
TN3663312Medicaid
KY9500536900OtherKENTUCKY MEDICAID
TNQ38800Medicare UPIN