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General NPI Number Information
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NPI Number | 1972696722
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Entity Type | Individual
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Provider Name | LISA FREDERICKSON O.D.
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Gender | Female
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 508 UPLAND ST
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City | KENAI
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State | AK
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Zip | 99611-8026
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Country | US
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Telephone | 907-335-7305
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Fax | 888-491-3360
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Provider Business Mailing Address
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Address Line | PO BOX 2409
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City | KENAI
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State | AK
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Zip | 99611-2409
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Country | US
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Telephone | 253-324-8764
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3574-TX
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 199077
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License Number State | AK
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