Healthcare Provider Details

I. General information

NPI: 1992509244
Provider Name (Legal Business Name): LISA KIERNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 GOLDEN POND BLVD
BONAIRE GA
31005-4427
US

IV. Provider business mailing address

119 GOLDEN POND BLVD
BONAIRE GA
31005-4427
US

V. Phone/Fax

Practice location:
  • Phone: 478-258-6636
  • Fax: 478-258-6636
Mailing address:
  • Phone: 478-258-6636
  • Fax: 478-258-6636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN258735
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberRN258735
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: