Provider Demographics
NPI:1699367698
Name:SMITH, KELLY DAWN (BSN,RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSN,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36065 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-553-5833
Mailing Address - Fax:
Practice Address - Street 1:458 TOWN SQ
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-2826
Practice Address - Country:US
Practice Address - Phone:254-553-5833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX802161163WP2201X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care