Healthcare Provider Details

I. General information

NPI: 1962291401
Provider Name (Legal Business Name): LAQUESHA LARENDA SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 BROWNLEE CIR
TIFTON GA
31794-1651
US

IV. Provider business mailing address

165 BROWNLEE CIR
TIFTON GA
31794-1651
US

V. Phone/Fax

Practice location:
  • Phone: 229-325-5384
  • Fax:
Mailing address:
  • Phone: 229-325-5384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberRN207444
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN207444
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: