Provider Demographics
NPI:1417461831
Name:WATSON, LISA D (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:WATSON
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 1:122 GORDON COMMERCIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5754
Mailing Address - Country:US
Mailing Address - Phone:706-845-4045
Mailing Address - Fax:706-845-4367
Practice Address - Street 1:59 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1209
Practice Address - Country:US
Practice Address - Phone:678-423-4610
Practice Address - Fax:770-254-7419
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAP032747164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse