Provider Demographics
NPI:1063994077
Name:CRUZ, STACY LYNN (LVN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:CRUZ
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 1:2303 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1431
Mailing Address - Country:US
Mailing Address - Phone:432-438-0716
Mailing Address - Fax:
Practice Address - Street 1:2303 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-1431
Practice Address - Country:US
Practice Address - Phone:432-438-0716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX194779164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse