Healthcare Provider Details

I. General information

NPI: 1639694276
Provider Name (Legal Business Name): KELLY AMANDA SMITH MSN, RN, CPNP-PC/AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 08/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

2040 MARKET ST APT 1104
PHILADELPHIA PA
19103-3369
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax:
Mailing address:
  • Phone: 585-739-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberSP017721
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: