Provider Demographics
NPI:1861009375
Name:SMITH, AMIELLE LYDIA (PAC)
Entity Type:Individual
Prefix:
First Name:AMIELLE
Middle Name:LYDIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AMIELLE
Other - Middle Name:LYDIA
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:4106 COLUMBIA RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1482
Mailing Address - Country:US
Mailing Address - Phone:706-863-1440
Mailing Address - Fax:706-863-5418
Practice Address - Street 1:4106 COLUMBIA RD STE 103
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-1482
Practice Address - Country:US
Practice Address - Phone:706-863-1440
Practice Address - Fax:706-863-5418
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant