Provider Demographics
NPI:1548344161
Name:NICHOLSON, LISA ILENE (LAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ILENE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1643
Mailing Address - Country:US
Mailing Address - Phone:619-772-4002
Mailing Address - Fax:619-234-4624
Practice Address - Street 1:2310 6TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1643
Practice Address - Country:US
Practice Address - Phone:619-772-4002
Practice Address - Fax:619-234-4624
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7347171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist