Healthcare Provider Details

I. General information

NPI: 1982803995
Provider Name (Legal Business Name): LISA ANNE SWIFT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 MONTREAL RD SUITE 207
TUCKER GA
30084-6900
US

IV. Provider business mailing address

PO BOX 1718
DEMOREST GA
33053-1718
US

V. Phone/Fax

Practice location:
  • Phone: 770-491-2622
  • Fax: 678-990-5847
Mailing address:
  • Phone: 706-754-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN130193
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: