Provider Demographics
NPI:1295181626
Name:HENRY, LISA D (LDO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:HENRY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SE EVERETT MALL WAY STE 320
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3279
Mailing Address - Country:US
Mailing Address - Phone:425-355-2377
Mailing Address - Fax:425-710-0895
Practice Address - Street 1:620 SE EVERETT MALL WAY STE 320
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3279
Practice Address - Country:US
Practice Address - Phone:425-355-2377
Practice Address - Fax:425-710-0895
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1615156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician