Healthcare Provider Details

I. General information

NPI: 1104453711
Provider Name (Legal Business Name): LISE WENDY FORESTAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WILLIE LEE PKWY
WARNER ROBINS GA
31088-8970
US

IV. Provider business mailing address

2490 RIVERSIDE DR STE B
MACON GA
31204-1787
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-6688
  • Fax: 478-333-6634
Mailing address:
  • Phone: 478-633-6706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12173
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: