Provider Demographics
NPI:1225094881
Name:NIX, LISA ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:NIX
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELDRIDGE
Mailing Address - State:IA
Mailing Address - Zip Code:52748-2023
Mailing Address - Country:US
Mailing Address - Phone:563-285-5744
Mailing Address - Fax:563-285-5744
Practice Address - Street 1:126 S CODY RD
Practice Address - Street 2:
Practice Address - City:LE CLAIRE
Practice Address - State:IA
Practice Address - Zip Code:52753-9236
Practice Address - Country:US
Practice Address - Phone:563-289-2020
Practice Address - Fax:563-289-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02189152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0223669Medicaid
IAAO1823Medicare UPIN
IAI1618Medicare ID - Type Unspecified