Healthcare Provider Details

I. General information

NPI: 1487585022
Provider Name (Legal Business Name): MISS KELSEY FAITH SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 PERIMETER DR
MOSCOW ID
83844-9803
US

IV. Provider business mailing address

702 NW 112TH CIR
VANCOUVER WA
98685-4156
US

V. Phone/Fax

Practice location:
  • Phone: 208-885-6111
  • Fax:
Mailing address:
  • Phone: 503-572-4732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: