Provider Demographics
NPI:1093269284
Name:LANCELIN, WALLISSA (OD)
Entity Type:Individual
Prefix:DR
First Name:WALLISSA
Middle Name:
Last Name:LANCELIN
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 1:101 TOBIANO TRCE
Mailing Address - Street 2:
Mailing Address - City:BROCK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-6748
Mailing Address - Country:US
Mailing Address - Phone:337-578-1830
Mailing Address - Fax:
Practice Address - Street 1:5700 OVERTON RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3220
Practice Address - Country:US
Practice Address - Phone:817-668-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1819-753AT152W00000X
TX9812TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist