Provider Demographics
NPI:1104422336
Name:SMALLEY, KAILI MICHELLE
Entity type:Individual
Prefix:
First Name:KAILI
Middle Name:MICHELLE
Last Name:SMALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N ROBINSON BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-8617
Mailing Address - Country:US
Mailing Address - Phone:208-249-7597
Mailing Address - Fax:
Practice Address - Street 1:12222 W BRIDGER BAY DR
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5081
Practice Address - Country:US
Practice Address - Phone:208-391-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty