Provider Demographics
NPI:1609899947
Name:WALL, LISA-JOY FULLER (OD)
Entity type:Individual
Prefix:
First Name:LISA-JOY
Middle Name:FULLER
Last Name:WALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JOY
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:505 RETAIL WAY STE 118
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-6480
Practice Address - Country:US
Practice Address - Phone:919-496-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904440Medicaid
NC093VAOtherBLUECROSS
NCP00959601OtherMEDICARE RAILROAD CARRIER
NCNC3004BMedicare PIN
NCNC3004FMedicare UPIN
NC093VAOtherBLUECROSS
NCNC3004AMedicare PIN
NC2474139AMedicare PIN
NCNC3004JMedicare UPIN
NC3004LMedicare PIN
NCNC3004CMedicare PIN