Healthcare Provider Details

I. General information

NPI: 1912821307
Provider Name (Legal Business Name): KIRSTEN KALLEY SMITH CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 5TH ST NW STE A2
BEMIDJI MN
56601-0030
US

IV. Provider business mailing address

15855 MAIN AVE 280
RED LAKE MN
56671-0280
US

V. Phone/Fax

Practice location:
  • Phone: 218-444-2718
  • Fax: 651-383-4937
Mailing address:
  • Phone: 218-679-3228
  • Fax: 651-383-4937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: