Provider Demographics
NPI:1780965525
Name:SMITH, MICHELLE LISA (APRN)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LISA
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3063
Mailing Address - Country:US
Mailing Address - Phone:203-556-2315
Mailing Address - Fax:
Practice Address - Street 1:982 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1913
Practice Address - Country:US
Practice Address - Phone:203-696-3260
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234788Medicaid