Provider Demographics
NPI:1083789473
Name:SMITH, MELISSA AVERETT (RDH, RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:AVERETT
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDH, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-2813
Mailing Address - Country:US
Mailing Address - Phone:478-627-3263
Mailing Address - Fax:
Practice Address - Street 1:2858 PINE STREET
Practice Address - Street 2:
Practice Address - City:UNADILLA
Practice Address - State:GA
Practice Address - Zip Code:31091
Practice Address - Country:US
Practice Address - Phone:478-627-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH005671124Q00000X
GARN133584163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered124Q00000XDental ProvidersDental Hygienist
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health