Healthcare Provider Details

I. General information

NPI: 1265215602
Provider Name (Legal Business Name): HAMILTON ELIJAH SMITH APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N 12TH ST STE 704
BROOKLYN NY
11249-1002
US

IV. Provider business mailing address

PO BOX 456
MCDONOUGH GA
30253-0456
US

V. Phone/Fax

Practice location:
  • Phone: 478-202-9589
  • Fax: 478-202-9589
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406272
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP322175
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: