Provider Demographics
NPI:1003050576
Name:POLING, LISA VIVIENNE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:VIVIENNE
Last Name:POLING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:VIVIENNE
Other - Last Name:MELNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 CHASTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5588
Mailing Address - Country:US
Mailing Address - Phone:678-797-2844
Mailing Address - Fax:678-797-2827
Practice Address - Street 1:1000 CHASTAIN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5588
Practice Address - Country:US
Practice Address - Phone:678-797-2844
Practice Address - Fax:678-797-2827
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN067035NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily