Healthcare Provider Details

I. General information

NPI: 1609740240
Provider Name (Legal Business Name): LANCINE CISSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 10/04/2025
Certification Date: 10/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 GRANDE RIVER RD
ATLANTA GA
30349-9126
US

IV. Provider business mailing address

5621 GRANDE RIVER RD
ATLANTA GA
30349-9126
US

V. Phone/Fax

Practice location:
  • Phone: 217-607-6243
  • Fax:
Mailing address:
  • Phone: 217-607-6243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberCJP1942
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: