Provider Demographics
NPI:1962940692
Name:SMITH, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
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 1:4841 LENORA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-7707
Mailing Address - Country:US
Mailing Address - Phone:404-510-3888
Mailing Address - Fax:770-679-9494
Practice Address - Street 1:4841 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-7707
Practice Address - Country:US
Practice Address - Phone:404-510-3888
Practice Address - Fax:770-679-9494
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN071509163W00000X, 163WC1500X, 163WG0600X, 163WH0200X, 163WM0705X
GANHA005147163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical