Healthcare Provider Details

I. General information

NPI: 1417415738
Provider Name (Legal Business Name): ASHLEY SMALLWOOD CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5582 MEMORIAL DR
STONE MOUNTAIN GA
30083-3215
US

IV. Provider business mailing address

706 DIXIE ST STE 220
CARROLLTON GA
30117-3889
US

V. Phone/Fax

Practice location:
  • Phone: 404-564-6703
  • Fax:
Mailing address:
  • Phone: 770-812-8825
  • Fax: 770-812-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number197976
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN197976
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: