Provider Demographics
NPI:1245788017
Name:SISEMORE, LAUREN (LPN)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SISEMORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 SPRING MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-8916
Mailing Address - Country:US
Mailing Address - Phone:423-260-4290
Mailing Address - Fax:
Practice Address - Street 1:4083 CLOUD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-8411
Practice Address - Country:US
Practice Address - Phone:706-820-6087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN083786164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1356799688Medicaid