=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487081105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LEWIS-SIMON FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2013
-----------------------------------------------------
Last Update Date | 10/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1605 MULKEY RD BLDG 2
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-956-3760
-----------------------------------------------------
Fax | 678-398-1930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3810 JIM OWENS RD NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30152-2324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-574-5843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | RN155957
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------