Provider Demographics
NPI:1508069915
Name:FOSS, LISA NICKLAWSKY
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:NICKLAWSKY
Last Name:FOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARY
Other - Last Name:NICKLAWSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4268 BROKEN ROCK LOOP
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-527-8826
Mailing Address - Fax:928-527-8826
Practice Address - Street 1:3150 N WINDING BROOK RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-774-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist