Provider Demographics
NPI:1386919769
Name:FETHEROLF, LISA (DC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:FETHEROLF
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5672 RIVER OAKS PL NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-4256
Mailing Address - Country:US
Mailing Address - Phone:941-544-3340
Mailing Address - Fax:
Practice Address - Street 1:44 DARBYS CROSSING DR STE 102A
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-6040
Practice Address - Country:US
Practice Address - Phone:770-439-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO08946111N00000X
IL038.012103111N00000X
FLCH10585111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor