Provider Demographics
NPI:1619226792
Name:SMITH, LISA ANN
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 E. BROOMFIELD ST.
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-779-9988
Mailing Address - Fax:989-779-9955
Practice Address - Street 1:1627 E. BROOMFIELD ST.
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-779-9988
Practice Address - Fax:989-779-9955
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker