Healthcare Provider Details

I. General information

NPI: 1770175309
Provider Name (Legal Business Name): AMANDA NICOLE SMITH MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12978 N MAIN ST
TRENTON GA
30752-2241
US

IV. Provider business mailing address

12978 N MAIN ST
TRENTON GA
30752-2241
US

V. Phone/Fax

Practice location:
  • Phone: 706-657-4183
  • Fax: 706-657-4270
Mailing address:
  • Phone: 706-657-4183
  • Fax: 706-657-4270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number260929
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28556
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: