Provider Demographics
NPI:1104176833
Name:SMIDEBUSH, KELLY (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:SMIDEBUSH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E REDSTONE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5350
Mailing Address - Country:US
Mailing Address - Phone:850-682-7212
Mailing Address - Fax:850-682-6302
Practice Address - Street 1:129 E REDSTONE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5350
Practice Address - Country:US
Practice Address - Phone:850-682-7212
Practice Address - Fax:850-682-6302
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9279024363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner