Provider Demographics
NPI:1245798032
Name:SMITH, KAITLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 SALEM GATE DR SE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1783
Mailing Address - Country:US
Mailing Address - Phone:770-285-3533
Mailing Address - Fax:770-502-6052
Practice Address - Street 1:343 SALEM GATE DR SE STE 100
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1783
Practice Address - Country:US
Practice Address - Phone:770-285-3533
Practice Address - Fax:770-502-6052
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9190261QU0200X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care