Provider Demographics
NPI:1396793576
Name:ELY, LISA M (OD08)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:ELY
Suffix:
Gender:F
Credentials:OD08
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:DYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:115 ALEXANDER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5145
Mailing Address - Country:US
Mailing Address - Phone:931-647-3208
Mailing Address - Fax:
Practice Address - Street 1:3315 GUTHRIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5507
Practice Address - Country:US
Practice Address - Phone:931-647-3208
Practice Address - Fax:931-552-8732
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU91951Medicare UPIN