Provider Demographics
NPI:1750337598
Name:SMITH, MARJORIE (CFNP)
Entity type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 PHILIP BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8737
Mailing Address - Country:US
Mailing Address - Phone:770-995-3307
Mailing Address - Fax:770-995-3300
Practice Address - Street 1:475 PHILIP BOULEVARD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-9999
Practice Address - Country:US
Practice Address - Phone:770-995-3307
Practice Address - Fax:770-995-3300
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN192533NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA439457490AMedicaid
GA061407OtherBC/BS OF GA GROUP #
GA511I500053Medicare PIN
GAGRP1806Medicare PIN
GAS60686Medicare UPIN