Provider Demographics
NPI:1023079423
Name:SMITH, LISA (CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:PAREDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:WESTSIDE COMMUNITY HEALTH SERVICES, INC.
Mailing Address - City:W. ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-602-7552
Mailing Address - Fax:651-602-7580
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:WESTSIDE COMMUNITY HEALTH SERVICES, INC.
Practice Address - City:W. ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-602-7552
Practice Address - Fax:651-602-7580
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124016-0367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNA9021019276OtherPREFERRED ONE
MN07-05977OtherMEDICA
MNHP24171OtherHEALTH PARTNERS
MN110675OtherUCARE
MN3F110NEOtherBCBS
MN021765400Medicaid
MNHP24171OtherHEALTH PARTNERS