Provider Demographics
NPI:1558490417
Name:SMITH, GWENDOLYN WILLIAMS (APRN,BC)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:WILLIAMS
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 FAIRCREST AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-9439
Mailing Address - Country:US
Mailing Address - Phone:706-798-5565
Mailing Address - Fax:
Practice Address - Street 1:2420 WINDSOR SPRING RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-4668
Practice Address - Country:US
Practice Address - Phone:706-790-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN075901363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health