Healthcare Provider Details

I. General information

NPI: 1508535451
Provider Name (Legal Business Name): STEPHANIE DIANA HOUSLEY RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/18/2021
Certification Date: 09/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N WILSON ST
BURLESON TX
76028-4167
US

IV. Provider business mailing address

PO BOX 40382
FORT WORTH TX
76140-0382
US

V. Phone/Fax

Practice location:
  • Phone: 817-382-1314
  • Fax:
Mailing address:
  • Phone: 817-382-1314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-86581
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-86581
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: