Provider Demographics
NPI:1336353895
Name:BARTELL, LISA MICHELLE (BACHELOR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:BARTELL
Suffix:
Gender:F
Credentials:BACHELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MARY HILL LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-4625
Mailing Address - Country:US
Mailing Address - Phone:404-765-4163
Mailing Address - Fax:404-765-4149
Practice Address - Street 1:1920 JOHN WESLEY AVE.
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-3606
Practice Address - Country:US
Practice Address - Phone:404-765-4166
Practice Address - Fax:404-765-4149
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133NOOOOOX133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist