Provider Demographics
NPI:1164428397
Name:SMITH, LISA CUNNINGHAM (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CUNNINGHAM
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:65 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4816
Practice Address - Country:US
Practice Address - Phone:864-987-7000
Practice Address - Fax:864-987-7020
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1165363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0265Medicaid
SCP01129674OtherRAILROAD MEDICARE
SCAA61807951Medicare PIN
SCP01129674OtherRAILROAD MEDICARE
SC6526Medicare PIN