=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477704039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE CRANDALL FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2008
-----------------------------------------------------
Last Update Date | 02/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5245 BUFORD HWY SUITE 106
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30071-2654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-903-0148
-----------------------------------------------------
Fax | 678-903-0175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14700 TAYLOR VALLEY WAY
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30004-8260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-580-0815
-----------------------------------------------------
Fax | 678-903-0175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN173213
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------