Provider Demographics
NPI:1659398345
Name:MCKENTLY, LISA RENEE (DC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:MCKENTLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 HIDDEN TRAIL RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2442
Mailing Address - Country:US
Mailing Address - Phone:404-520-0526
Mailing Address - Fax:
Practice Address - Street 1:4425 S COBB DR SE
Practice Address - Street 2:SUITE G
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6368
Practice Address - Country:US
Practice Address - Phone:770-444-9191
Practice Address - Fax:770-444-9391
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor