Healthcare Provider Details

I. General information

NPI: 1679655989
Provider Name (Legal Business Name): BETH D SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 E TOLLISON ST
BAXLEY GA
31513-0120
US

IV. Provider business mailing address

PO BOX 2070
BAXLEY GA
31515-2070
US

V. Phone/Fax

Practice location:
  • Phone: 912-367-9841
  • Fax:
Mailing address:
  • Phone: 912-367-9841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberRN047845
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: