Healthcare Provider Details

I. General information

NPI: 1356065718
Provider Name (Legal Business Name): MARY KATHERINE SMITH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W 10TH ST NE
ROME GA
30165-2640
US

IV. Provider business mailing address

409 W 10TH ST NE
ROME GA
30165-2640
US

V. Phone/Fax

Practice location:
  • Phone: 706-406-5093
  • Fax:
Mailing address:
  • Phone: 706-406-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN250856
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN250856
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: