Healthcare Provider Details

I. General information

NPI: 1790988657
Provider Name (Legal Business Name): DIANNE TERRELL SMITH I RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVE. S W
FORT MCPHERSON GA
30330
US

IV. Provider business mailing address

115 FAIRWAY TRL
COVINGTON GA
30014-3973
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-0400
  • Fax: 404-464-0415
Mailing address:
  • Phone: 404-464-0400
  • Fax: 404-464-0415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN 045158
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: