Provider Demographics
NPI:1902975915
Name:CREIGHTON, LISA D
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:D
Last Name:CREIGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 WOOD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1107
Mailing Address - Country:US
Mailing Address - Phone:360-510-4432
Mailing Address - Fax:360-318-0822
Practice Address - Street 1:605 WOOD CREEK DR
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1107
Practice Address - Country:US
Practice Address - Phone:369-510-4432
Practice Address - Fax:360-318-0822
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001440156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031342Medicaid