Healthcare Provider Details

I. General information

NPI: 1467946400
Provider Name (Legal Business Name): HARRIETT VIRGINIA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

60 ROBERTS LN
COVINGTON GA
30014-0935
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN237463
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: