Provider Demographics
NPI:1306868708
Name:SMITH LANE, KELLIE
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:
Last Name:SMITH LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KELLIE
Other - Middle Name:SMITH
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3502 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4454
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-364-2600
Practice Address - Street 1:3502 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4454
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:601-364-2600
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865577363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01425217Medicaid
MS500002361Medicare Oscar/Certification