Provider Demographics
NPI:1366117657
Name:SMITH, REBECCA ANNE (CPNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 COUNTRY CLUB DR BLDG 200A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7212
Mailing Address - Country:US
Mailing Address - Phone:770-389-4543
Mailing Address - Fax:
Practice Address - Street 1:245 COUNTRY CLUB DR BLDG 200A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7212
Practice Address - Country:US
Practice Address - Phone:770-389-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175958363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics