Provider Demographics
NPI:1437167939
Name:SMITH, SUSAN D (MSN CPNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 A HOWELL FERRY RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:678-473-4738
Mailing Address - Fax:679-473-4739
Practice Address - Street 1:3645 A HOWELL FERRY RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:678-473-4738
Practice Address - Fax:679-473-4739
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN050646208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA796001599AMedicaid