Provider Demographics
NPI:1376832691
Name:SMITH, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD
Mailing Address - Street 2:STE 304E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6150
Mailing Address - Country:US
Mailing Address - Phone:314-741-0911
Mailing Address - Fax:314-653-3671
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:STE 304E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-741-0911
Practice Address - Fax:314-653-3671
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO072802163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse