Provider Demographics
NPI:1003241522
Name:SMITH, LISA DIAN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:DIAN
Other - Last Name:MIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1806 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3639
Mailing Address - Country:US
Mailing Address - Phone:229-386-1528
Mailing Address - Fax:229-388-0556
Practice Address - Street 1:1806 LEE AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3639
Practice Address - Country:US
Practice Address - Phone:229-386-1528
Practice Address - Fax:229-388-0556
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176448363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner