Provider Demographics
NPI:1093383309
Name:WILLIS, STEPHANIE (LVN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14139 BUCHER AVE
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1442
Mailing Address - Country:US
Mailing Address - Phone:818-290-5309
Mailing Address - Fax:
Practice Address - Street 1:14139 BUCHER AVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1442
Practice Address - Country:US
Practice Address - Phone:818-290-5309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235391164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse