Provider Demographics
NPI:1679950554
Name:SMITH, FAWN B (NP-C)
Entity type:Individual
Prefix:MRS
First Name:FAWN
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 HIGHWAY 119 S
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-3021
Mailing Address - Country:US
Mailing Address - Phone:912-754-0382
Mailing Address - Fax:912-754-0225
Practice Address - Street 1:459 HIGHWAY 119 S
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:GA
Practice Address - Zip Code:31329-3021
Practice Address - Country:US
Practice Address - Phone:912-754-0382
Practice Address - Fax:912-754-0225
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175547363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health