Provider Demographics
NPI:1215946959
Name:SMITH, LISA A (CRNP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5665
Practice Address - Street 1:509 SE RIVERSIDE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2579
Practice Address - Country:US
Practice Address - Phone:772-286-5007
Practice Address - Fax:772-286-0018
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9337278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004774800Medicaid
FLY0A9COtherFLORIDA BLUE
FL004774800Medicaid
MD180042Y4HMedicare PIN