Provider Demographics
NPI:1124645395
Name:SMALLEY, KISHA (FNP)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:SMALLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 GAMBIER CV
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-6273
Mailing Address - Country:US
Mailing Address - Phone:904-536-3032
Mailing Address - Fax:
Practice Address - Street 1:117 GAMBIER CV
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-6273
Practice Address - Country:US
Practice Address - Phone:904-536-3032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF07200350363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care