Healthcare Provider Details

I. General information

NPI: 1235341017
Provider Name (Legal Business Name): LISA SIMS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 MEDICAL BLVD
STOCKBRIDGE GA
30281-7218
US

IV. Provider business mailing address

203 MEDICAL BLVD
STOCKBRIDGE GA
30281-7218
US

V. Phone/Fax

Practice location:
  • Phone: 770-892-0273
  • Fax: 470-878-1495
Mailing address:
  • Phone: 770-892-0273
  • Fax: 470-878-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN1155250
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: