Provider Demographics
NPI:1053596833
Name:LIGHTFOOT, LANNY BRIAN (MS)
Entity type:Individual
Prefix:
First Name:LANNY
Middle Name:BRIAN
Last Name:LIGHTFOOT
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2098 TERON TRCE STE 300
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1667
Mailing Address - Country:US
Mailing Address - Phone:770-614-4060
Mailing Address - Fax:
Practice Address - Street 1:2098 TERON TRCE STE 300
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1667
Practice Address - Country:US
Practice Address - Phone:770-614-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-30
Last Update Date:2007-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0014512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer