Provider Demographics
NPI:1750318366
Name:SMITH, JUDITH A (FNP-C)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SHADOWBROOK DR SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-8411
Mailing Address - Country:US
Mailing Address - Phone:706-232-4634
Mailing Address - Fax:706-331-5171
Practice Address - Street 1:3720 DAVINCI CT STE 400
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-7625
Practice Address - Country:US
Practice Address - Phone:706-844-4340
Practice Address - Fax:706-413-3653
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN045165 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA544926171CMedicaid
Q23531Medicare UPIN
GA544926171CMedicaid
GAPO00471363Medicare PIN