Provider Demographics
NPI:1942822788
Name:SMITH, DIVIA L (NP)
Entity Type:Individual
Prefix:
First Name:DIVIA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11611 STOCKDALE CT
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-6422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11611 STOCKDALE CT
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-6422
Practice Address - Country:US
Practice Address - Phone:803-487-5918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA197065363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily