Healthcare Provider Details

I. General information

NPI: 1750004651
Provider Name (Legal Business Name): EMMELINE WYNN LOMBARD PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5403 HILLANDALE PARK CT STE B
LITHONIA GA
30058-8845
US

IV. Provider business mailing address

5403 HILLANDALE PARK CT STE B
LITHONIA GA
30058-8845
US

V. Phone/Fax

Practice location:
  • Phone: 770-817-0224
  • Fax: 770-817-0228
Mailing address:
  • Phone: 770-817-0224
  • Fax: 770-817-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: