Provider Demographics
NPI:1669087995
Name:HARRIS, EDLISA (LVN)
Entity type:Individual
Prefix:
First Name:EDLISA
Middle Name:
Last Name:HARRIS
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 1:4500 BRENTWOOD STAIR RD APT 1131
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1621
Mailing Address - Country:US
Mailing Address - Phone:469-855-1519
Mailing Address - Fax:
Practice Address - Street 1:4500 BRENTWOOD STAIR RD APT 1131
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-1621
Practice Address - Country:US
Practice Address - Phone:469-855-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350925164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse