Provider Demographics
NPI:1053457176
Name:WILLIS, TERESA HALLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:HALLEY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 CHAPMAN JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:LA
Mailing Address - Zip Code:71225-8669
Mailing Address - Country:US
Mailing Address - Phone:318-547-9400
Mailing Address - Fax:
Practice Address - Street 1:3421 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2355
Practice Address - Country:US
Practice Address - Phone:318-388-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN031851 APO1344367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1900443Medicaid
LA59827Medicare PIN
LA1900443Medicaid