Provider Demographics
NPI:1821897430
Name:SMITH, ANGELIQUE N
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:N
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3388 IN BLOOM WAY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30011-2551
Mailing Address - Country:US
Mailing Address - Phone:770-990-4971
Mailing Address - Fax:
Practice Address - Street 1:3388 IN BLOOM WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:GA
Practice Address - Zip Code:30011-2551
Practice Address - Country:US
Practice Address - Phone:770-990-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25041817172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver