Provider Demographics
NPI:1336525138
Name:SMITH, IDA (NP)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
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 1:2375 LAGO DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-5251
Mailing Address - Country:US
Mailing Address - Phone:770-478-4048
Mailing Address - Fax:
Practice Address - Street 1:1260 HIGHWAY 54 W STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4525
Practice Address - Country:US
Practice Address - Phone:770-719-4620
Practice Address - Fax:770-719-4622
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN128300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily