Provider Demographics
NPI:1275000721
Name:MITCHELL, LISA ANN (NP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:NUNNALLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:19 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1533
Practice Address - Country:US
Practice Address - Phone:762-235-3960
Practice Address - Fax:706-233-8505
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN280273363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner