Healthcare Provider Details

I. General information

NPI: 1497144612
Provider Name (Legal Business Name): KELLY SMERLING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR
FE WARREN AFB WY
82005-3906
US

IV. Provider business mailing address

115 MONTALTO DR 15A
CHEYENNE WY
82007-6519
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-5661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number19497
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: