Healthcare Provider Details

I. General information

NPI: 1902497142
Provider Name (Legal Business Name): RUSSELL WILLIAM SMITH DNP, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2021
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE STE 1185
ATLANTA GA
30308-2236
US

IV. Provider business mailing address

1835 SAVOY DR STE 300
ATLANTA GA
30341-1071
US

V. Phone/Fax

Practice location:
  • Phone: 404-223-0792
  • Fax: 404-223-5815
Mailing address:
  • Phone: 678-288-9555
  • Fax: 678-288-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN298954
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: