Provider Demographics
NPI:1891063707
Name:SMITH, ANGELA (CNA-PCT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNA-PCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 ROY HUIE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-1826
Mailing Address - Country:US
Mailing Address - Phone:770-709-1741
Mailing Address - Fax:
Practice Address - Street 1:474 ROY HUIE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-1826
Practice Address - Country:US
Practice Address - Phone:770-709-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN000003210171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor