Provider Demographics
NPI:1134505118
Name:SMITH, TARA (FNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 OCILLA RD
Mailing Address - Street 2:P.O. BOX 1287
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2207
Mailing Address - Country:US
Mailing Address - Phone:912-384-1900
Mailing Address - Fax:
Practice Address - Street 1:1101 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2207
Practice Address - Country:US
Practice Address - Phone:912-384-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily