Provider Demographics
NPI:1962908533
Name:JOHNSTON, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JOHNSTON
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 1:402 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-4935
Mailing Address - Country:US
Mailing Address - Phone:405-201-1267
Mailing Address - Fax:
Practice Address - Street 1:402 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4935
Practice Address - Country:US
Practice Address - Phone:580-798-4523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKM081019050OtherDRIVERS LICENSE