Basic Information
| Provider Information | |||||||||
| NPI: | 1235880634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 606 FOREST PINE DR | ||||||||
| Address2: | |||||||||
| City: | BALL GROUND | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301075196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706084407 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707935000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2022 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN259993 | GA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.