Healthcare Provider Details

I. General information

NPI: 1962049494
Provider Name (Legal Business Name): CHANTALETTE TYSHERIA SMITH MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 BLUE SPRINGS RD NW STE 503
KENNESAW GA
30144-1038
US

IV. Provider business mailing address

PO BOX 447
ELLABELL GA
31308-0447
US

V. Phone/Fax

Practice location:
  • Phone: 404-857-9575
  • Fax:
Mailing address:
  • Phone: 912-414-9923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN248645
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN248645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: