Provider Demographics
NPI:1235341017
Name:SIMS, LISA (NP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:SIMS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7218
Mailing Address - Country:US
Mailing Address - Phone:770-892-0273
Mailing Address - Fax:470-878-1495
Practice Address - Street 1:203 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7218
Practice Address - Country:US
Practice Address - Phone:770-892-0273
Practice Address - Fax:470-878-1495
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN1155250363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003144411BMedicaid
GA003144411AMedicaid
GA003144411BMedicaid