Healthcare Provider Details

I. General information

NPI: 1942452065
Provider Name (Legal Business Name): LISA G LAMAR CERTIFIEDHHHIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 MARTIN LUTHER KING JR BLVD
TENNILLE GA
31089-1440
US

IV. Provider business mailing address

517 MARTIN LUTHER KING JR. BLOUVARD
TENNILLE GA
31089
US

V. Phone/Fax

Practice location:
  • Phone: 478-553-9412
  • Fax:
Mailing address:
  • Phone: 478-553-9412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberCN000016927
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberCN0000016927
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: