Healthcare Provider Details

I. General information

NPI: 1992621866
Provider Name (Legal Business Name): ATIYA SMITH-WILSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 HEPBURN RD
ORANGE PARK FL
32065-5639
US

IV. Provider business mailing address

369 HEPBURN RD
ORANGE PARK FL
32065-5639
US

V. Phone/Fax

Practice location:
  • Phone: 904-534-7793
  • Fax: 904-534-7793
Mailing address:
  • Phone:
  • Fax: 904-534-7793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11048466
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: