Healthcare Provider Details

I. General information

NPI: 1982954194
Provider Name (Legal Business Name): LISA M ALES NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 RESERVE PKWY
MCDONOUGH GA
30253
US

IV. Provider business mailing address

2023 RESERVE PKWY
MCDONOUGH GA
30253
US

V. Phone/Fax

Practice location:
  • Phone: 770-296-8446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN119193
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: