Provider Demographics
NPI:1831860428
Name:SMITH, KELLY LORRIANE (FNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LORRIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W PEACE ST APT 311
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-5021
Mailing Address - Country:US
Mailing Address - Phone:832-588-6328
Mailing Address - Fax:
Practice Address - Street 1:251 KEISLER DR STE 201
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7091
Practice Address - Country:US
Practice Address - Phone:919-322-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015055363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5015055OtherNC BON