Provider Demographics
NPI:1205691680
Name:BAXTER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BAXTER
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 1:6711 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:KY
Mailing Address - Zip Code:41001-1025
Mailing Address - Country:US
Mailing Address - Phone:859-635-1888
Mailing Address - Fax:859-635-1941
Practice Address - Street 1:6711 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-1025
Practice Address - Country:US
Practice Address - Phone:859-635-1888
Practice Address - Fax:859-635-1941
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110780156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician