Provider Demographics
NPI:1588345599
Name:SMITH, TIARA
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 DANIEL DR STE D
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4169
Mailing Address - Country:US
Mailing Address - Phone:770-589-2228
Mailing Address - Fax:
Practice Address - Street 1:7225 DANIEL DR STE D
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4169
Practice Address - Country:US
Practice Address - Phone:770-589-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1923979133NN1002X
GA1923977171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education