Provider Demographics
NPI:1407871635
Name:JOHNSON-SMITH, AVIS FELECIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:AVIS
Middle Name:FELECIA
Last Name:JOHNSON-SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-2360
Mailing Address - Country:US
Mailing Address - Phone:229-431-2030
Mailing Address - Fax:229-431-2030
Practice Address - Street 1:707 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2360
Practice Address - Country:US
Practice Address - Phone:229-431-2030
Practice Address - Fax:229-431-2030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR066396363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS95131Medicare UPIN
GA50BBDFXMedicare ID - Type Unspecified