Provider Demographics
NPI:1114678323
Name:SMART, LISA (DRIVER/OWNER)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMART
Suffix:
Gender:F
Credentials:DRIVER/OWNER
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:560 STAGE COACH RD LOT 1
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:GA
Mailing Address - Zip Code:31779-4072
Mailing Address - Country:US
Mailing Address - Phone:229-319-8815
Mailing Address - Fax:229-683-3748
Practice Address - Street 1:560 STAGE COACH RD LOT 1
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:GA
Practice Address - Zip Code:31779-4072
Practice Address - Country:US
Practice Address - Phone:229-319-8815
Practice Address - Fax:229-683-3748
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver