Provider Demographics
NPI:1205217791
Name:SMITH, TIFFANY BENTLEY (AGACNP)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:BENTLEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE STE 350
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1129
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 350
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1129
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN204485363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner