Provider Demographics
NPI:1083667448
Name:SWOFFORD, LISA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:SWOFFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:112 N CUTHBERT ST
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-3419
Mailing Address - Country:US
Mailing Address - Phone:229-758-3002
Mailing Address - Fax:229-758-9415
Practice Address - Street 1:103 W PINE ST
Practice Address - Street 2:
Practice Address - City:COLQUITT
Practice Address - State:GA
Practice Address - Zip Code:39837-3526
Practice Address - Country:US
Practice Address - Phone:229-758-3002
Practice Address - Fax:229-758-9415
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN132537NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA913150787AMedicaid
GA50BBJXZMedicare ID - Type Unspecified