Provider Demographics
NPI:1528526548
Name:SMITH, KISHA MESHUN (AGNP-C)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:MESHUN
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:KISHA
Other - Middle Name:MESHUN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN
Mailing Address - Street 1:508 BETHELVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-4825
Mailing Address - Country:US
Mailing Address - Phone:850-624-5436
Mailing Address - Fax:
Practice Address - Street 1:1133 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5085
Practice Address - Country:US
Practice Address - Phone:678-604-1045
Practice Address - Fax:678-604-4175
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCO-000001363L00000X, 363LA2200X, 363LG0600X
GARN194819163WI0500X, 163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WX0200XNursing Service ProvidersRegistered NurseOncology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology