Basic Information
| Provider Information | |||||||||
| NPI: | 1083066526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | PURISIMA | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 SE STURDEVANT RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973912125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412650581 | ||||||||
| FaxNumber: | 5415746252 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 SW COAST HWY | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973655288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654947 | ||||||||
| FaxNumber: | 5415747670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2016 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201605283RN | OR | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 201605283RN | 01 | OR | RN-OREGON | OTHER |