Provider Demographics
NPI:1366874471
Name:SMITH, KELLEY ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST
Mailing Address - Street 2:WALLER BLDG. SUITE B 06
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2677
Mailing Address - Country:US
Mailing Address - Phone:740-356-8051
Mailing Address - Fax:
Practice Address - Street 1:1735 27TH ST
Practice Address - Street 2:WALLER BLDG. SUITE B 06
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2677
Practice Address - Country:US
Practice Address - Phone:740-356-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142017207P00000X
OH58004885207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty