Provider Demographics
NPI:1720599376
Name:SMITH, SHERONDA (DNP, FNP, AG-ACNP)
Entity Type:Individual
Prefix:DR
First Name:SHERONDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DNP, FNP, AG-ACNP
Other - Prefix:
Other - First Name:SHERONDA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:766 LAKELAND DR STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4610
Mailing Address - Country:US
Mailing Address - Phone:601-383-3440
Mailing Address - Fax:601-368-3441
Practice Address - Street 1:766 LAKELAND DR STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4610
Practice Address - Country:US
Practice Address - Phone:601-383-3440
Practice Address - Fax:601-368-3441
Is Sole Proprietor?:No
Enumeration Date:2017-10-22
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23370363L00000X
MS889439163W00000X
MS902395363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse