Provider Demographics
NPI:1720586365
Name:SAMPLES, LISA A (CPNP-AC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ASHLEY
Other - Last Name:BUMPUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4407 BLACK HILLS DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-1422
Mailing Address - Country:US
Mailing Address - Phone:678-591-7015
Mailing Address - Fax:
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:470-732-5299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224696363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics