Healthcare Provider Details

I. General information

NPI: 1063784668
Provider Name (Legal Business Name): CLAIRE SUZANNE SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 GORDON COMMERCIAL DR STE B
LAGRANGE GA
30240-5753
US

IV. Provider business mailing address

120 GORDON COMMERCIAL DR STE B
LAGRANGE GA
30240-5753
US

V. Phone/Fax

Practice location:
  • Phone: 706-845-4054
  • Fax: 706-845-4430
Mailing address:
  • Phone: 706-845-4054
  • Fax: 706-845-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN108180
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: