Basic Information
| Provider Information | |||||||||
| NPI: | 1275000721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NUNNALLY | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622351000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19 REDMOND RD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622353960 | ||||||||
| FaxNumber: | 7062338505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN280273 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.