Healthcare Provider Details

I. General information

NPI: 1104176833
Provider Name (Legal Business Name): KELLY SMIDEBUSH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5350
US

IV. Provider business mailing address

129 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5350
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-7212
  • Fax: 850-682-6302
Mailing address:
  • Phone: 850-682-7212
  • Fax: 850-682-6302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9279024
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: