Healthcare Provider Details

I. General information

NPI: 1396979621
Provider Name (Legal Business Name): ALICIA LOUISE SMITH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 THREE RIVERS DR NE
ROME GA
30161-4999
US

IV. Provider business mailing address

140 THREE RIVERS DR NE
ROME GA
30161-4999
US

V. Phone/Fax

Practice location:
  • Phone: 706-232-1300
  • Fax:
Mailing address:
  • Phone: 706-232-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN192262
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: