Provider Demographics
NPI:1972795995
Name:LIPSEY, TICARIA LYNNE (MD)
Entity Type:Individual
Prefix:MS
First Name:TICARIA
Middle Name:LYNNE
Last Name:LIPSEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HANDLEY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2178
Mailing Address - Country:US
Mailing Address - Phone:770-997-5714
Mailing Address - Fax:
Practice Address - Street 1:190 HANDLEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2178
Practice Address - Country:US
Practice Address - Phone:770-997-5714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068058207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126108AMedicaid