Provider Demographics
NPI:1255708103
Name:SMART, KELLY JEAN (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:SMART
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:215 GLASGOW ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NY
Mailing Address - Zip Code:14433-1222
Mailing Address - Country:US
Mailing Address - Phone:315-902-3020
Mailing Address - Fax:315-923-7906
Practice Address - Street 1:215 GLASGOW ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NY
Practice Address - Zip Code:14433-1222
Practice Address - Country:US
Practice Address - Phone:315-902-3020
Practice Address - Fax:315-923-7906
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY532167-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool