Provider Demographics
NPI:1609899947
Name:FULLER, LISA JOY (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOY
Last Name:FULLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 RETAIL WAY STE 118
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-6480
Practice Address - Country:US
Practice Address - Phone:919-496-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093VAOtherBLUECROSS
NC5904440Medicaid
NCP00959601OtherMEDICARE RAILROAD CARRIER
NCNC3004BMedicare PIN
NCNC3004FMedicare UPIN
NC093VAOtherBLUECROSS
NCNC3004AMedicare PIN
NC2474139AMedicare PIN
NCNC3004JMedicare UPIN
NC3004LMedicare PIN
NCNC3004CMedicare PIN