Provider Demographics
NPI:1700502028
Name:SMITH, CARLIE (PAC)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CARLIE
Other - Middle Name:
Other - Last Name:OVERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2200 MEDICAL CENTER BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7768
Mailing Address - Country:US
Mailing Address - Phone:678-312-2700
Mailing Address - Fax:678-312-2730
Practice Address - Street 1:2200 MEDICAL CENTER BLVD STE 350
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7768
Practice Address - Country:US
Practice Address - Phone:678-312-2700
Practice Address - Fax:678-312-2730
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant