Healthcare Provider Details

I. General information

NPI: 1902975915
Provider Name (Legal Business Name): MRS. LISA D CREIGHTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WOOD CREEK DR
LYNDEN WA
98264-1107
US

IV. Provider business mailing address

605 WOOD CREEK DR
LYNDEN WA
98264-1107
US

V. Phone/Fax

Practice location:
  • Phone: 369-510-4432
  • Fax: 360-318-0822
Mailing address:
  • Phone: 360-510-4432
  • Fax: 360-318-0822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO00001440
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: