Provider Demographics
NPI:1760197842
Name:SMITH, KEIUNDRA NICHOLE
Entity Type:Individual
Prefix:
First Name:KEIUNDRA
Middle Name:NICHOLE
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 1:7064 OAKBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-6013
Mailing Address - Country:US
Mailing Address - Phone:470-445-4029
Mailing Address - Fax:
Practice Address - Street 1:7064 OAKBROOK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-6013
Practice Address - Country:US
Practice Address - Phone:470-445-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581330Medicaid
GA581331OtherPRIVATE SERVICE