Provider Demographics
NPI:1952601759
Name:SMEESTER, KELLY L (RD, PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:SMEESTER
Suffix:
Gender:F
Credentials:RD, PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:TAUBENECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, PA-C
Mailing Address - Street 1:10103 RIDGEGATE PKWY STE 312
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5525
Mailing Address - Country:US
Mailing Address - Phone:303-788-8888
Mailing Address - Fax:866-456-4594
Practice Address - Street 1:10103 RIDGEGATE PKWY STE 312
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5525
Practice Address - Country:US
Practice Address - Phone:303-788-8888
Practice Address - Fax:866-456-4594
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO915688133V00000X
CO3106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83270086Medicaid
CO83270086Medicaid