Provider Demographics
NPI:1740379247
Name:GRAY-SMITH, PATRICIA THERESA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:THERESA
Last Name:GRAY-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 1:2795 MAIN ST W BLDG 27
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3164
Mailing Address - Country:US
Mailing Address - Phone:770-985-8001
Mailing Address - Fax:770-985-8028
Practice Address - Street 1:2795 MAIN ST W BLDG 27
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3164
Practice Address - Country:US
Practice Address - Phone:770-985-8001
Practice Address - Fax:770-985-8028
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167539363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA015829263AMedicaid
GA015829263AMedicaid