Basic Information
| Provider Information | |||||||||
| NPI: | 1902303985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHADE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 985 MANOR DR SE | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300804213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043129925 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1605 CHANTILLY DR NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303243270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047855437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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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 | 363LP0200X | 233880 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.