Healthcare Provider Details

I. General information

NPI: 1508572306
Provider Name (Legal Business Name): LANEATRIA LYNN WILLIS CPHT, CHES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 CLOUD LN
DECATUR GA
30034-2253
US

IV. Provider business mailing address

PO BOX 467102
ATLANTA GA
31146-7102
US

V. Phone/Fax

Practice location:
  • Phone: 404-536-0864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: