Provider Demographics
NPI:1851689467
Name:SMITH, KELLY O (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:O
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:111 SALEM TPKE STE 7
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-7403
Mailing Address - Country:US
Mailing Address - Phone:860-859-2262
Mailing Address - Fax:860-859-9819
Practice Address - Street 1:111 SALEM TPKE STE 7
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-7403
Practice Address - Country:US
Practice Address - Phone:860-859-2262
Practice Address - Fax:860-859-9819
Is Sole Proprietor?:No
Enumeration Date:2011-07-16
Last Update Date:2025-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT002588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant