1790156255 NPI number — MS. LYSSA EILEEN SOLOMON SIMPSON

Table of content: MS. LYSSA EILEEN SOLOMON SIMPSON (NPI 1790156255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790156255 NPI number — MS. LYSSA EILEEN SOLOMON SIMPSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOLOMON SIMPSON
Provider First Name:
LYSSA
Provider Middle Name:
EILEEN
Provider Name Prefix Text:
MS.
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:
1790156255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1124
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30074-1124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-553-3597
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 SOUTHLAKE PLAZA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORROW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30260-1756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-553-3597
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2015

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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