Healthcare Provider Details

I. General information

NPI: 1134675325
Provider Name (Legal Business Name): RAEGAN MARREE SMITH MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 12TH AVE
ALBANY GA
31707-3251
US

IV. Provider business mailing address

2210 12TH AVE
ALBANY GA
31707-3251
US

V. Phone/Fax

Practice location:
  • Phone: 812-340-1554
  • Fax:
Mailing address:
  • Phone: 812-340-1554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2255A2300X
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003737
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: