Healthcare Provider Details

I. General information

NPI: 1134505118
Provider Name (Legal Business Name): TARA D SMITH APRN,FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

IV. Provider business mailing address

724 PINE NEEDLE RD
DOUGLAS GA
31535-6512
US

V. Phone/Fax

Practice location:
  • Phone: 912-338-6338
  • Fax:
Mailing address:
  • Phone: 912-327-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN213039
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN213039
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: