Provider Demographics
NPI:1013200757
Name:SMITH, LEESA M (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:LEESA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10447B LONGMIRE RD
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1357
Mailing Address - Country:US
Mailing Address - Phone:253-970-3244
Mailing Address - Fax:
Practice Address - Street 1:10447B LONGMIRE RD
Practice Address - Street 2:
Practice Address - City:FORT LEWIS
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-970-3244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians