Healthcare Provider Details

I. General information

NPI: 1699790253
Provider Name (Legal Business Name): LISA ROCHELLE GRAHAM RN, BSN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 W CROGAN ST
LAWRENCEVILLE GA
30046-6914
US

IV. Provider business mailing address

2250 OAK RD UNIT 1541
SNELLVILLE GA
30078-1914
US

V. Phone/Fax

Practice location:
  • Phone: 404-396-4417
  • Fax:
Mailing address:
  • Phone: 404-396-4417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberRN135816
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: