Provider Demographics
NPI:1730820317
Name:DE LA CRUZ, LIEZL (CPNP)
Entity type:Individual
Prefix:
First Name:LIEZL
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 MEADOWCREEK CT
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3803
Mailing Address - Country:US
Mailing Address - Phone:678-612-3606
Mailing Address - Fax:
Practice Address - Street 1:1400 TULLIE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2309
Practice Address - Country:US
Practice Address - Phone:404-785-5497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA293015363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics