Provider Demographics
NPI:1083739759
Name:MALONE, LISA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12623 MERIDIAN E
Mailing Address - Street 2:B1-A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3469
Mailing Address - Country:US
Mailing Address - Phone:253-848-0377
Mailing Address - Fax:253-848-1317
Practice Address - Street 1:12623 MERIDIAN E
Practice Address - Street 2:B1-A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3469
Practice Address - Country:US
Practice Address - Phone:253-848-0377
Practice Address - Fax:253-848-1317
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician