Provider Demographics
NPI:1588137418
Name:CHRISTINE, STACY CARON (LVN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:CARON
Last Name:CHRISTINE
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 1:1208 N RODEO ST
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-4056
Mailing Address - Country:US
Mailing Address - Phone:903-424-4861
Mailing Address - Fax:
Practice Address - Street 1:1208 N RODEO ST
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-4056
Practice Address - Country:US
Practice Address - Phone:903-424-4861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313302164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse