Basic Information
| Provider Information | |||||||||
| NPI: | 1396063368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURDETT | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 136 W DYKES ST | ||||||||
| Address2: | |||||||||
| City: | COCHRAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310146844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789346926 | ||||||||
| FaxNumber: | 4789348887 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 W DYKES ST | ||||||||
| Address2: | |||||||||
| City: | COCHRAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310146844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789346926 | ||||||||
| FaxNumber: | 4789348887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2010 | ||||||||
| LastUpdateDate: | 05/14/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN156452NP | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.