Provider Demographics
NPI:1932752458
Name:NISWONGER, ALISHA ROSE (OD)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:ROSE
Last Name:NISWONGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4180 OLD MILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-2408
Mailing Address - Country:US
Mailing Address - Phone:770-776-9000
Mailing Address - Fax:678-293-8499
Practice Address - Street 1:4180 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-2408
Practice Address - Country:US
Practice Address - Phone:770-776-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA003166152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision