Provider Demographics
NPI:1497523989
Name:REARDON, LISA DENISE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DENISE
Last Name:REARDON
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 1:700 MARKETPLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-2115
Mailing Address - Country:US
Mailing Address - Phone:609-585-2403
Mailing Address - Fax:609-585-2189
Practice Address - Street 1:700 MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08691-2115
Practice Address - Country:US
Practice Address - Phone:609-585-2403
Practice Address - Fax:609-585-2189
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00315200156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician