Provider Demographics
NPI:1235737354
Name:SMITH, ADRIENNE (PA)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
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 746725
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6725
Mailing Address - Country:US
Mailing Address - Phone:469-727-6675
Mailing Address - Fax:
Practice Address - Street 1:3889 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-6634
Practice Address - Country:US
Practice Address - Phone:901-401-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4069363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant