Healthcare Provider Details

I. General information

NPI: 1619503059
Provider Name (Legal Business Name): LISA SMOTRICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

898 HIGHLANDS BLVD
PALM HARBOR FL
34684-2827
US

V. Phone/Fax

Practice location:
  • Phone: 727-510-4768
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN9308998
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: