Healthcare Provider Details

I. General information

NPI: 1720445166
Provider Name (Legal Business Name): KELLY LYNN SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 WABASH AVE
SPRINGFIELD IL
62704-5351
US

IV. Provider business mailing address

1999 WABASH AVE
SPRINGFIELD IL
62704-5351
US

V. Phone/Fax

Practice location:
  • Phone: 217-523-2273
  • Fax: 217-523-2272
Mailing address:
  • Phone: 217-523-2273
  • Fax: 217-523-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041289431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: