Provider Demographics
NPI:1396979621
Name:SMITH, ALICIA LOUISE (CPNP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 THREE RIVERS DR NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-4999
Mailing Address - Country:US
Mailing Address - Phone:706-232-1300
Mailing Address - Fax:
Practice Address - Street 1:140 THREE RIVERS DR NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4999
Practice Address - Country:US
Practice Address - Phone:706-232-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN192262363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA299653708AMedicaid