Provider Demographics
NPI:1043216385
Name:SMITH, QUANNA FETTER (APRN, FNP, BC)
Entity Type:Individual
Prefix:MRS
First Name:QUANNA
Middle Name:FETTER
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN, FNP, BC
Other - Prefix:
Other - First Name:QUANNA
Other - Middle Name:DAVON
Other - Last Name:FETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP, BC
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-4278
Practice Address - Street 1:5131 ODONOVAN DR STE 201
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4791
Practice Address - Country:US
Practice Address - Phone:225-374-0220
Practice Address - Fax:225-374-0221
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1461547Medicaid
4H535Medicare PIN