Provider Demographics
NPI:1730425307
Name:SMITH, BRENDA GAYLE (PMHCNS-BC, APRN/BC)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:GAYLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PMHCNS-BC, APRN/BC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:SIMPSON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 HAWKINS ST APT G
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-1154
Mailing Address - Country:US
Mailing Address - Phone:706-974-5968
Mailing Address - Fax:
Practice Address - Street 1:20 HAWKINS ST APT G
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1154
Practice Address - Country:US
Practice Address - Phone:706-974-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-29
Last Update Date:2012-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN185152364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health