Healthcare Provider Details

I. General information

NPI: 1164428397
Provider Name (Legal Business Name): LISA CUNNINGHAM SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 INTERNATIONAL DR
GREENVILLE SC
29615-4816
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-987-7000
  • Fax: 864-987-7020
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1165
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: