Provider Demographics
NPI:1194735472
Name:FOMENOFF, LISA NICOLE (DC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:NICOLE
Last Name:FOMENOFF
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14777 NE 40TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3300
Mailing Address - Country:US
Mailing Address - Phone:425-883-2543
Mailing Address - Fax:425-867-1109
Practice Address - Street 1:14777 NE 40TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3300
Practice Address - Country:US
Practice Address - Phone:425-883-2543
Practice Address - Fax:425-867-1109
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8861020Medicare PIN