Provider Demographics
NPI:1548704463
Name:SMITH, BETHANY LASKY (AANP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LASKY
Last Name:SMITH
Suffix:
Gender:F
Credentials:AANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 BILL KENNEDY WAY SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-6835
Mailing Address - Country:US
Mailing Address - Phone:404-446-4726
Mailing Address - Fax:404-446-4727
Practice Address - Street 1:490 BILL KENNEDY WAY SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-6835
Practice Address - Country:US
Practice Address - Phone:404-446-4726
Practice Address - Fax:404-446-4727
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN204273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily