Provider Demographics
NPI:1396100111
Name:WALSH, LISA MARIE (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 SHALLOWFORD RD STE B7B
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5021
Mailing Address - Country:US
Mailing Address - Phone:678-905-6880
Mailing Address - Fax:678-866-2358
Practice Address - Street 1:4343 SHALLOWFORD RD STE B7B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:678-905-6880
Practice Address - Fax:678-866-2358
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA220575363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily