Provider Demographics
NPI:1669630141
Name:SMITH, LISA JENEEN (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JENEEN
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 1:3838 N RURAL ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2930
Mailing Address - Country:US
Mailing Address - Phone:317-221-2306
Mailing Address - Fax:317-221-2336
Practice Address - Street 1:3838 N RURAL ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2930
Practice Address - Country:US
Practice Address - Phone:317-221-2306
Practice Address - Fax:317-221-2336
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28156163A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse