Provider Demographics
NPI:1295228088
Name:WILLIS, STACY LASHUN (LVN)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:LASHUN
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:PO BOX 2557
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77410-2557
Mailing Address - Country:US
Mailing Address - Phone:888-693-7474
Mailing Address - Fax:888-510-5280
Practice Address - Street 1:1400 BROADFIELD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5162
Practice Address - Country:US
Practice Address - Phone:888-693-7474
Practice Address - Fax:888-510-5280
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX194684164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse