Provider Demographics
NPI:1669904884
Name:SMITH, MONA DENNISON (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:DENNISON
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LESTER RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4786
Mailing Address - Country:US
Mailing Address - Phone:912-681-8999
Mailing Address - Fax:
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:912-486-1433
Practice Address - Fax:912-871-2261
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239737163W00000X, 363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health