Healthcare Provider Details

I. General information

NPI: 1033700257
Provider Name (Legal Business Name): LEE JOSEPH SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 05/11/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

IV. Provider business mailing address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8000
  • Fax:
Mailing address:
  • Phone: 715-268-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: