Provider Demographics
NPI:1174252407
Name:MINK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MINK
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 1:1851 HIGHWAY 192 W
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-3032
Mailing Address - Country:US
Mailing Address - Phone:606-878-2011
Mailing Address - Fax:606-878-2014
Practice Address - Street 1:1851 HIGHWAY 192 W
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3032
Practice Address - Country:US
Practice Address - Phone:606-878-2011
Practice Address - Fax:606-878-2014
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165262156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician