1417143181 NPI number — MRS. DONNA LISA MOXLEY LASSITER

Table of content: MRS. DONNA LISA MOXLEY LASSITER (NPI 1417143181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417143181 NPI number — MRS. DONNA LISA MOXLEY LASSITER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOXLEY LASSITER
Provider First Name:
DONNA
Provider Middle Name:
LISA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417143181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10929 US HIGHWAY 301 S
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
STATESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30458-7774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-764-7839
Provider Business Mailing Address Fax Number:
912-489-1519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10929 US HIGHWAY 301 S
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-7774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-764-7839
Provider Business Practice Location Address Fax Number:
912-489-1519
Provider Enumeration Date:
09/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835G0303X , with the licence number:  015513 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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