Provider Demographics
NPI:1558900993
Name:SMITH, CHARNIECE
Entity Type:Individual
Prefix:
First Name:CHARNIECE
Middle Name:
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 1:8071 UPATOI RDG
Mailing Address - Street 2:
Mailing Address - City:UPATOI
Mailing Address - State:GA
Mailing Address - Zip Code:31829-2161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 W COTA ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2265
Practice Address - Country:US
Practice Address - Phone:360-205-8004
Practice Address - Fax:360-839-2820
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61154507363LP0808X
GARN232587363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health