Basic Information
| Provider Information | |||||||||
| NPI: | 1225488620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1869 | ||||||||
| Address2: | |||||||||
| City: | FLETCHER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287321869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8286508076 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 SKYLAND INN DR | ||||||||
| Address2: | |||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287047714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286815327 | ||||||||
| FaxNumber: | 8286819846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS018950 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2021-02165 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.