Individual
LISA-JOY FULLER WALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
505 RETAIL WAY STE 118, LOUISBURG, NC 27549-6480
(919) 496-1156
Mailing address
8614 WESTWOOD CENTER DR FL 9, VIENNA, VA 22182-2442
(703) 847-8899
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1998
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
093VA
BLUECROSS
NC
05
—
5904440
—
NC
01
—
P00959601
MEDICARE RAILROAD CARRIER
NC
Enumeration date
07/26/2006
Last updated
08/27/2024
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