Provider Demographics
NPI:1154773539
Name:SMITH, LISA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
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 1:1400 BRADLEY LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3688
Mailing Address - Country:US
Mailing Address - Phone:706-256-2525
Mailing Address - Fax:706-256-2705
Practice Address - Street 1:1400 BRADLEY LAKE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3688
Practice Address - Country:US
Practice Address - Phone:706-256-2525
Practice Address - Fax:706-256-2705
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN194505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily