Provider Demographics
NPI:1073091831
Name:SMITH, LAQUNITA
Entity Type:Individual
Prefix:
First Name:LAQUNITA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAQUNITA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FAMILY NURSE PRACTIT
Mailing Address - Street 1:2126 LEAFMORE CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-4328
Mailing Address - Country:US
Mailing Address - Phone:770-339-3005
Mailing Address - Fax:
Practice Address - Street 1:2126 LEAFMORE CT
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4328
Practice Address - Country:US
Practice Address - Phone:770-339-3005
Practice Address - Fax:770-339-3005
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN118830363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily