Provider Demographics
NPI:1407313729
Name:SMITH, KELLY HANN (CPNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:HANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:HANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4109 WAKE FOREST RD STE 300
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-2508
Mailing Address - Country:US
Mailing Address - Phone:919-250-3478
Mailing Address - Fax:
Practice Address - Street 1:4109 WAKE FOREST RD STE 300
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-2508
Practice Address - Country:US
Practice Address - Phone:919-250-3478
Practice Address - Fax:919-250-6272
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50180232080A0000X, 363LP0200X
VA0024177340363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine