Provider Demographics
NPI:1104960400
Name:SMITH, KELLY ANN (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:STANICHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2000 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7222
Mailing Address - Country:US
Mailing Address - Phone:630-978-4810
Mailing Address - Fax:
Practice Address - Street 1:2000 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7222
Practice Address - Country:US
Practice Address - Phone:630-978-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119988207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine