Provider Demographics
NPI:1457583593
Name:SMITH, LISA FUDGE (LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FUDGE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 EVERGREEN PKWY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7909
Mailing Address - Country:US
Mailing Address - Phone:720-934-3008
Mailing Address - Fax:303-482-1946
Practice Address - Street 1:2942 EVERGREEN PKWY
Practice Address - Street 2:SUITE 305
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7909
Practice Address - Country:US
Practice Address - Phone:720-934-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1458171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist