Provider Demographics
NPI:1083830558
Name:LYFORD, NANCY WHITFORD (MED CCCSP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:WHITFORD
Last Name:LYFORD
Suffix:
Gender:F
Credentials:MED CCCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 KENDALL COVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340
Mailing Address - Country:US
Mailing Address - Phone:678-793-1874
Mailing Address - Fax:678-209-0602
Practice Address - Street 1:3932 KENDALL COVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340
Practice Address - Country:US
Practice Address - Phone:678-793-1874
Practice Address - Fax:678-209-0602
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP000830235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10057588OtherAMERIGROUP