Healthcare Provider Details

I. General information

NPI: 1720599376
Provider Name (Legal Business Name): SHERONDA SMITH DNP, FNP, AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHERONDA WILSON

II. Dates (important events)

Enumeration Date: 10/22/2017
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 LAKELAND DR STE A
JACKSON MS
39216-4610
US

IV. Provider business mailing address

6255 W SUNSET BLVD FL 21
LOS ANGELES CA
90028-7422
US

V. Phone/Fax

Practice location:
  • Phone: 601-383-3440
  • Fax: 601-368-3441
Mailing address:
  • Phone: 323-860-5200
  • Fax: 323-467-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number889439
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number23370
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number902395
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: