Individual
IDA SMITH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
1260 HIGHWAY 54 W STE 101, FAYETTEVILLE, GA 30214-4525
(770) 719-4620
(770) 719-4622
Mailing address
2375 LAGO DR, JONESBORO, GA 30236-5251
(770) 478-4048
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
RN128300
GA
Other
Enumeration date
08/04/2015
Last updated
08/04/2015
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