Healthcare Provider Details

I. General information

NPI: 1780036152
Provider Name (Legal Business Name): MARIANNE LISSADE AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 ROCKBRIDGE RD STE 15B
STONE MOUNTAIN GA
30087-3306
US

IV. Provider business mailing address

PO BOX 740015
ATLANTA GA
30374-0015
US

V. Phone/Fax

Practice location:
  • Phone: 470-444-3134
  • Fax: 470-276-4370
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN147281
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN147281
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: