=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699008409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA M AVERY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2009
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1260 HIGHWAY 54 W
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-619-1910
-----------------------------------------------------
Fax | 214-619-1914
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1260 HIGHWAY 54 W
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-619-1910
-----------------------------------------------------
Fax | 214-619-1914
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME 94226
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | ME 94226
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 053486
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------