Provider Demographics
NPI:1427211515
Name:JOHNSON, LISA MARIE (OPTICIAN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:JOHNSON
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 1:4054 COMMONWEATH AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-9000
Mailing Address - Country:US
Mailing Address - Phone:715-833-1220
Mailing Address - Fax:715-833-1297
Practice Address - Street 1:4054 COMMONWEATH AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-9000
Practice Address - Country:US
Practice Address - Phone:715-833-1220
Practice Address - Fax:715-833-1297
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38460300Medicaid