Provider Demographics
NPI:1114191897
Name:FUNSTON, LISA MICHELLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:FUNSTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10175 LITTLE PATUXENT PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2655
Mailing Address - Country:US
Mailing Address - Phone:706-681-8927
Mailing Address - Fax:
Practice Address - Street 1:2425 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4501
Practice Address - Country:US
Practice Address - Phone:706-322-1700
Practice Address - Fax:706-320-0456
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA113877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily