Healthcare Provider Details

I. General information

NPI: 1124295332
Provider Name (Legal Business Name): KARL SMART
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 S MILLEDGE AVE
ATHENS GA
30605-1252
US

IV. Provider business mailing address

411 HOLMAN AVE
ATHENS GA
30606-2666
US

V. Phone/Fax

Practice location:
  • Phone: 706-498-9560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number581186
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number17645
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number2794
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN279645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: