Healthcare Provider Details

I. General information

NPI: 1942739768
Provider Name (Legal Business Name): JOHN MARSHALL SMITH II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 WATSON BLVD
WARNER ROBINS GA
31093-3606
US

IV. Provider business mailing address

1707 WATSON BLVD
WARNER ROBINS GA
31093-3606
US

V. Phone/Fax

Practice location:
  • Phone: 478-929-8030
  • Fax: 478-929-8095
Mailing address:
  • Phone: 478-929-8030
  • Fax: 478-929-8095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN198334
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: