MEDICARE: LILLIAN DAVENPORT PARKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0807X	Child & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist	RN052630 CNSPMH	GA

General Provider Information

NPI Number	:	1336298264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LILLIAN DAVENPORT PARKER

Provider Business Mailing Address
First Line	:	3629 WINDMILL RD
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-2106
Country	:	US
Telephone Number	:	770-987-1881
Fax Number	:

Provider Business Practice Location Address
First Line	:	3629 WINDMILL RD
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-2106
Country	:	US
Telephone Number	:	770-987-1881
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL NURSE SPECIALIST
Name	:	MS. LILLIAN GRACE PARKER
Credential	:	CNSPMH
Telephone Number	:	770-987-1881

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	06/20/2008

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