Provider Demographics
NPI:1619388253
Name:GRIFFIN, LASONYA
Entity Type:Individual
Prefix:
First Name:LASONYA
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 BUXTON DR
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:GA
Mailing Address - Zip Code:30426-4306
Mailing Address - Country:US
Mailing Address - Phone:706-871-3828
Mailing Address - Fax:
Practice Address - Street 1:1303 38TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1315
Practice Address - Country:US
Practice Address - Phone:966-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18790363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily