Healthcare Provider Details

I. General information

NPI: 1376824417
Provider Name (Legal Business Name): LISA M WEST RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 05/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 B COLUMBIA DRIVE
CARROLLTON GA
30117
US

IV. Provider business mailing address

PO BOX 537
TEMPLE GA
30179-0537
US

V. Phone/Fax

Practice location:
  • Phone: 770-755-5304
  • Fax: 770-573-1935
Mailing address:
  • Phone: 770-826-1590
  • Fax: 770-573-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License NumberRN137895
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN137895
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN137895
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: