Healthcare Provider Details

I. General information

NPI: 1528056660
Provider Name (Legal Business Name): LISA M PLOCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 10TH AVE SUITE 200
COLUMBUS GA
31901-3700
US

IV. Provider business mailing address

PO BOX 1038
COLUMBUS GA
31902-1038
US

V. Phone/Fax

Practice location:
  • Phone: 706-321-3745
  • Fax: 706-321-3749
Mailing address:
  • Phone: 706-660-6148
  • Fax: 706-660-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN075180
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: