Provider Demographics
NPI:1790914604
Name:HISCOCK, DANA PETERSEN (ACNP)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:PETERSEN
Last Name:HISCOCK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:ALICE
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-847-9999
Mailing Address - Fax:404-531-8466
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-847-9999
Practice Address - Fax:404-531-8466
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203502363LA2100X
GARN200031363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145155BMedicaid
GA003145155AMedicaid
GA003145155AMedicaid
TX8L16470Medicare PIN