Healthcare Provider Details

I. General information

NPI: 1336965359
Provider Name (Legal Business Name): LAKIN STEPHENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3995 S COBB DR SE
SMYRNA GA
30080-6342
US

IV. Provider business mailing address

3539 MOUNT TABOR CHURCH RD
DALLAS GA
30157-7102
US

V. Phone/Fax

Practice location:
  • Phone: 770-434-4567
  • Fax:
Mailing address:
  • Phone: 912-501-2690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13768
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: