Provider Demographics
NPI:1760694954
Name:SMITH, LISA J (RN,MSN,NP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN,MSN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18926 WILDHORSE CREEK
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-519-4084
Mailing Address - Fax:
Practice Address - Street 1:17300 N. OUTER 40
Practice Address - Street 2:STE 100
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005
Practice Address - Country:US
Practice Address - Phone:636-519-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3N29261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO104229OtherRN LICENSE NUMBER