Provider Demographics
NPI:1699549543
Name:WATSON, STACEY
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 FAIR WEATHER DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-4934
Mailing Address - Country:US
Mailing Address - Phone:469-439-1956
Mailing Address - Fax:
Practice Address - Street 1:19539 DAWN CANYON RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-6097
Practice Address - Country:US
Practice Address - Phone:469-437-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility