Provider Demographics
NPI:1710387881
Name:BUSH, LISA (MS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JOHNSON FERRY ROAD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1611
Mailing Address - Country:US
Mailing Address - Phone:404-851-6284
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY ROAD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1611
Practice Address - Country:US
Practice Address - Phone:404-851-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1710387881OtherMEDICARE AND MEDICAID