Basic Information
| Provider Information | |||||||||
| NPI: | 1437357159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLETT | ||||||||
| FirstName: | LUKISHA | ||||||||
| MiddleName: | DOMALLY | ||||||||
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| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DOMALLY | ||||||||
| OtherFirstName: | LUKISHA | ||||||||
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| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22311 E DANIEL OAK CIR | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773894017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813233568 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 155 LOUETTA CROSSING | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815280278 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05258 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.