Provider Demographics
NPI:1942898473
Name:PETERSON-LYLES, FANESHIA (FNP)
Entity Type:Individual
Prefix:
First Name:FANESHIA
Middle Name:
Last Name:PETERSON-LYLES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 HUDSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7250
Mailing Address - Country:US
Mailing Address - Phone:470-641-5996
Mailing Address - Fax:
Practice Address - Street 1:1046 RIDGE AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-1640
Practice Address - Country:US
Practice Address - Phone:404-688-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2024-03-05
Deactivation Date:2021-01-20
Deactivation Code:
Reactivation Date:2021-07-12
Provider Licenses
StateLicense IDTaxonomies
GA259066163W00000X, 363LF0000X, 363LF0000X, 163WH1000X, 163WI0500X, 163WW0000X, 376J00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942898473OtherNPI