Provider Demographics
NPI:1891269916
Name:LANDIS, BISSELL
Entity Type:Individual
Prefix:
First Name:BISSELL
Middle Name:
Last Name:LANDIS
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 1:2865 CONCORD DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5010
Mailing Address - Country:US
Mailing Address - Phone:404-909-3185
Mailing Address - Fax:
Practice Address - Street 1:1405 CLIFTON ROAD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30332-0001
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN264493163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse