Provider Demographics
NPI:1215255971
Name:SMITH, ELIZABETH (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:35 SAVANNAH CIR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-6653
Mailing Address - Country:US
Mailing Address - Phone:678-517-7775
Mailing Address - Fax:
Practice Address - Street 1:223 PERSON ST STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5733
Practice Address - Country:US
Practice Address - Phone:678-517-7775
Practice Address - Fax:910-483-7116
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA126444163WH0200X
NC149819163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601983Medicaid