Provider Demographics
NPI:1073342309
Name:SMITH, KELLY RAE (CRNP-PMH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15515 BRICE HOLLOW RD SE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-8605
Mailing Address - Country:US
Mailing Address - Phone:240-522-7977
Mailing Address - Fax:
Practice Address - Street 1:618 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2113
Practice Address - Country:US
Practice Address - Phone:724-986-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR231851363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health