Provider Demographics
NPI:1275881823
Name:PHILLIPS, LISA D (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 BROADRICK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3009
Mailing Address - Country:US
Mailing Address - Phone:706-226-3434
Mailing Address - Fax:706-226-4820
Practice Address - Street 1:1436 BROADRICK DR
Practice Address - Street 2:SUITE B
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3009
Practice Address - Country:US
Practice Address - Phone:706-226-3434
Practice Address - Fax:706-226-4820
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16722363L00000X
GARN247137363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003164332AMedicaid
GA03279387OtherAMERIGROUP
GA2025052I67Medicare PIN