Healthcare Provider Details

I. General information

NPI: 1467366476
Provider Name (Legal Business Name): KELLY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 JACKSON ST
YREKA CA
96097-2823
US

IV. Provider business mailing address

4703 LAKE SHASTINA DR
WEED CA
96094-9474
US

V. Phone/Fax

Practice location:
  • Phone: 530-842-3561
  • Fax:
Mailing address:
  • Phone: 530-842-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberF2931607E1
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: