Healthcare Provider Details

I. General information

NPI: 1528611522
Provider Name (Legal Business Name): DANYELLE M SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 PARKER RD SE STE A120
CONYERS GA
30094-6665
US

IV. Provider business mailing address

565 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4308
US

V. Phone/Fax

Practice location:
  • Phone: 770-922-5696
  • Fax: 770-922-3842
Mailing address:
  • Phone: 770-995-5131
  • Fax: 770-995-3482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN194165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: