Provider Demographics
NPI:1407502396
Name:SMITH, LAURA (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JUNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 EXETER RD STE 250
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3931
Practice Address - Country:US
Practice Address - Phone:901-767-5864
Practice Address - Fax:901-767-6591
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905198363LA2100X
TN31383363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care