Provider Demographics
NPI:1386059053
Name:NOLA, ALISA (OD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:NOLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GODDARD
Mailing Address - State:KS
Mailing Address - Zip Code:67052-9256
Mailing Address - Country:US
Mailing Address - Phone:316-512-1171
Mailing Address - Fax:
Practice Address - Street 1:7700 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-1772
Practice Address - Country:US
Practice Address - Phone:316-685-1802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3386152W00000X
TX8861T152WV0400X
KS1987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy