Healthcare Provider Details

I. General information

NPI: 1669904884
Provider Name (Legal Business Name): MONA DENNISON SMITH NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FAIR RD
STATESBORO GA
30458-1683
US

IV. Provider business mailing address

6 LESTER RD
STATESBORO GA
30458-4786
US

V. Phone/Fax

Practice location:
  • Phone: 912-486-1433
  • Fax: 912-871-2261
Mailing address:
  • Phone: 912-681-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN239737
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN239737
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN239737
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: