1992384945 NPI number — MRS. YOLONDA COLEMAN SMITH AGACNP

Table of content: MRS. YOLONDA COLEMAN SMITH AGACNP (NPI 1992384945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992384945 NPI number — MRS. YOLONDA COLEMAN SMITH AGACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
YOLONDA
Provider Middle Name:
COLEMAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AGACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLEMAN
Provider Other First Name:
YOLONDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1992384945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 STONEBROOK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39056-9684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-910-1264
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6508 DOGWOOD VIEW PKWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39213-7868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-532-7685
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  904204 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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