Healthcare Provider Details

I. General information

NPI: 1497869689
Provider Name (Legal Business Name): DAPHENE SMITH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 REGENCY PARK DR STE 110
MCDONOUGH GA
30253-7076
US

IV. Provider business mailing address

1825 HIGHWAY 34 E STE 1200
NEWNAN GA
30265-6416
US

V. Phone/Fax

Practice location:
  • Phone: 404-996-0126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085002952
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009234
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number085-002952
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2008018559
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002952
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: