Provider Demographics
NPI:1710354238
Name:SMITH, LISA DAWN (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BROADWAY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5201
Mailing Address - Country:US
Mailing Address - Phone:207-947-0469
Mailing Address - Fax:207-947-5368
Practice Address - Street 1:55 BROADWAY
Practice Address - Street 2:SUITE #2
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5201
Practice Address - Country:US
Practice Address - Phone:207-947-0469
Practice Address - Fax:207-947-5368
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP151125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily