Provider Demographics
NPI:1003936790
Name:SMITH, LISA LAJUNE (PT, MED)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LAJUNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, MED
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MCGHEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, MED
Mailing Address - Street 1:120 WYNGATE WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2458
Mailing Address - Country:US
Mailing Address - Phone:770-719-7183
Mailing Address - Fax:770-719-7189
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-7183
Practice Address - Fax:770-719-7189
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist