Provider Demographics
NPI:1902303985
Name:SMITH, SHADE (NP)
Entity Type:Individual
Prefix:
First Name:SHADE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 MANOR DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4213
Mailing Address - Country:US
Mailing Address - Phone:404-312-9925
Mailing Address - Fax:
Practice Address - Street 1:1605 CHANTILLY DR NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3270
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA233880363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics