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General NPI Number Information
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NPI Number | 1093269284
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Entity Type | Individual
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Provider Name | WALLISSA LANCELIN O.D.
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Gender | Female
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Dates
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Enumeration Date | 08/05/2016
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Last Update Date | 10/22/2023
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Provider Practice Location Address
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Address Line | 5700 OVERTON RIDGE BLVD
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City | FORT WORTH
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State | TX
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Zip | 76132-3220
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Country | US
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Telephone | 817-668-6852
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Fax |
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Provider Business Mailing Address
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Address Line | 101 TOBIANO TRCE
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City | BROCK
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State | TX
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Zip | 76087-6748
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Country | US
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Telephone | 337-578-1830
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1819-753AT
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 9812TG
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License Number State | TX
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