Provider Demographics
NPI:1881097277
Name:SMITH, MELISSA ANN (PNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 KEENELAND DR
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-5917
Mailing Address - Country:US
Mailing Address - Phone:706-255-8917
Mailing Address - Fax:
Practice Address - Street 1:2080 KEENELAND DR
Practice Address - Street 2:
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-5917
Practice Address - Country:US
Practice Address - Phone:706-255-8917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN145936363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics