Provider Demographics
NPI:1902407414
Name:KELLY RAE SMITH DNP APRN LLC
Entity Type:Organization
Organization Name:KELLY RAE SMITH DNP APRN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:502-396-0237
Mailing Address - Street 1:PO BOX 37270
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1214
Mailing Address - Country:US
Mailing Address - Phone:502-396-0237
Mailing Address - Fax:833-449-5152
Practice Address - Street 1:13402 CREEKVIEW RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9028
Practice Address - Country:US
Practice Address - Phone:502-396-0237
Practice Address - Fax:833-449-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-03
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100951070Medicaid