Healthcare Provider Details

I. General information

NPI: 1205503927
Provider Name (Legal Business Name): AMANDA DAWN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 MOUNTAIN CITY RD
CLAYTON GA
30525-3072
US

IV. Provider business mailing address

4668 BEACON RIDGE LN
FLOWERY BRANCH GA
30542-6317
US

V. Phone/Fax

Practice location:
  • Phone: 706-960-9533
  • Fax:
Mailing address:
  • Phone: 770-274-9054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN271516
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: