Provider Demographics
NPI:1588902340
Name:SMITH, KELLON SEAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:KELLON
Middle Name:SEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BALTIMORE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2301
Mailing Address - Country:US
Mailing Address - Phone:301-723-4965
Mailing Address - Fax:301-723-4809
Practice Address - Street 1:12500 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6393
Practice Address - Country:US
Practice Address - Phone:240-964-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203959163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical