Provider Demographics
NPI:1932199700
Name:SMITH, KELLY
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:SMITH
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 1:9201 CYPRESS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4941
Mailing Address - Country:US
Mailing Address - Phone:239-481-3343
Mailing Address - Fax:239-482-5227
Practice Address - Street 1:9201 CYPRESS LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4941
Practice Address - Country:US
Practice Address - Phone:239-481-3343
Practice Address - Fax:239-482-5227
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 5210156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician