Provider Demographics
NPI:1285375774
Name:BONNER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 MCCLAVE DR.
Mailing Address - Street 2:STE. #210 PMB1046
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1952
Mailing Address - Country:US
Mailing Address - Phone:404-600-7014
Mailing Address - Fax:
Practice Address - Street 1:2544 MCCLAVE DR
Practice Address - Street 2:STE. #210 PMB1046
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-1952
Practice Address - Country:US
Practice Address - Phone:404-600-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver