Healthcare Provider Details

I. General information

NPI: 1063194041
Provider Name (Legal Business Name): LISA YSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 3RD AVE
INTERNATIONAL FALLS MN
56649-2637
US

IV. Provider business mailing address

1607 7TH AVE E
INTERNATIONAL FALLS MN
56649-3024
US

V. Phone/Fax

Practice location:
  • Phone: 218-283-2525
  • Fax: 218-283-9694
Mailing address:
  • Phone: 218-290-8533
  • Fax: 218-283-9694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: