Basic Information
| Provider Information | |||||||||
| NPI: | 1245798032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KAITLYN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 343 SALEM GATE DR SE STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300131783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702853533 | ||||||||
| FaxNumber: | 7705026052 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 SALEM GATE DR SE STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300131783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702853533 | ||||||||
| FaxNumber: | 7705026052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 9190 | GA | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 363AM0700X | 9190 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.