Provider Demographics
NPI:1083261689
Name:NESMITH, MARQUAIL DEVON
Entity Type:Individual
Prefix:
First Name:MARQUAIL
Middle Name:DEVON
Last Name:NESMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 FOSTER CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-1261
Mailing Address - Country:US
Mailing Address - Phone:770-892-7555
Mailing Address - Fax:
Practice Address - Street 1:114 FOSTER CIR # 114
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-1261
Practice Address - Country:US
Practice Address - Phone:770-892-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053312786174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist