Healthcare Provider Details

I. General information

NPI: 1710354238
Provider Name (Legal Business Name): LISA DAWN SMITH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BROADWAY SUITE #2
BANGOR ME
04401-5201
US

IV. Provider business mailing address

55 BROADWAY SUITE #2
BANGOR ME
04401-5201
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0469
  • Fax: 207-947-5368
Mailing address:
  • Phone: 207-947-0469
  • Fax: 207-947-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP151125
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: