Provider Demographics
NPI:1386407187
Name:SMITH, LEEZA CAROLINE (FNP)
Entity type:Individual
Prefix:MRS
First Name:LEEZA
Middle Name:CAROLINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14458 SPYGLASS PT
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-8334
Mailing Address - Country:US
Mailing Address - Phone:573-300-6608
Mailing Address - Fax:
Practice Address - Street 1:1648 W HARPER ST STE 2
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4110
Practice Address - Country:US
Practice Address - Phone:573-609-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023050148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily