Provider Demographics
NPI:1407983893
Name:SMITH, CELESTE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5095 PEACHTREE PKWY
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2524
Mailing Address - Country:US
Mailing Address - Phone:770-209-9299
Mailing Address - Fax:
Practice Address - Street 1:5095 PEACHTREE PKWY
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2524
Practice Address - Country:US
Practice Address - Phone:770-209-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN137082363LF0000X
MO2020031543363LF0000X
GA137082NP363LF0000X
LAAP07492363LF0000X
FLARNP9326031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBLFWMedicare UPIN