Provider Demographics
NPI:1114411212
Name:BURR, STACY L (LVN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:BURR
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:MANDRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3004 GUS DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-3007
Mailing Address - Country:US
Mailing Address - Phone:832-403-8946
Mailing Address - Fax:
Practice Address - Street 1:3004 GUS DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-3007
Practice Address - Country:US
Practice Address - Phone:832-403-8946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220236164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse