Provider Demographics
NPI:1689840399
Name:NICHOLSON, LISA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16931 MOUNT OLIVET RD
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-7530
Mailing Address - Country:US
Mailing Address - Phone:937-248-9479
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-41362207V00000X
IN01068067A207V00000X
WAMD61023448207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology