Provider Demographics
NPI:1437357159
Name:WILLETT, LUKISHA DOMALLY (PA)
Entity Type:Individual
Prefix:
First Name:LUKISHA
Middle Name:DOMALLY
Last Name:WILLETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LUKISHA
Other - Middle Name:
Other - Last Name:DOMALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:22311 E DANIEL OAK CIR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-4017
Mailing Address - Country:US
Mailing Address - Phone:281-323-3568
Mailing Address - Fax:
Practice Address - Street 1:155 LOUETTA CROSSING
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373
Practice Address - Country:US
Practice Address - Phone:281-528-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant