Basic Information
| Provider Information | |||||||||
| NPI: | 1588698880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369326 | ||||||||
| FaxNumber: | 7708369358 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369326 | ||||||||
| FaxNumber: | 7708369358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN107296 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 364SA2100X | RN107296 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 306726231C | 05 | GA | MEDICAID | 306726231G | 05 | GA | MEDICAID |