Provider Demographics
NPI:1568965994
Name:DONALDSON, LISA AMANDA (ATC, MBA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:AMANDA
Last Name:DONALDSON
Suffix:
Gender:F
Credentials:ATC, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9304 W PLAINFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2118
Mailing Address - Country:US
Mailing Address - Phone:414-388-1918
Mailing Address - Fax:
Practice Address - Street 1:2701 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5563
Practice Address - Country:US
Practice Address - Phone:714-559-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20000178802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer