Provider Demographics
NPI:1689638124
Name:SMITH, LYNNE D (FNP-C)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-0749
Mailing Address - Country:US
Mailing Address - Phone:229-468-9166
Mailing Address - Fax:229-468-9188
Practice Address - Street 1:119 NORMAN DORMINY DR STE A
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-9069
Practice Address - Country:US
Practice Address - Phone:229-423-5437
Practice Address - Fax:229-424-0868
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN60915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000580522CMedicaid
GA000580522DMedicaid