Provider Demographics
NPI:1114104767
Name:LIGHTBOURNE, MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:LIGHTBOURNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 LENORA CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-972-0340
Mailing Address - Fax:770-972-0379
Practice Address - Street 1:2356 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3233
Practice Address - Country:US
Practice Address - Phone:770-972-0340
Practice Address - Fax:770-972-0379
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine