Healthcare Provider Details

I. General information

NPI: 1386059053
Provider Name (Legal Business Name): ALISA NOLA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 10/27/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 E KELLOGG DR
WICHITA KS
67207-1772
US

IV. Provider business mailing address

6 LAKEWOOD DR
GODDARD KS
67052-9256
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-1802
  • Fax:
Mailing address:
  • Phone: 316-512-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3386
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number8861T
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1987
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: