Provider Demographics
NPI:1053645697
Name:WILLIS, MISTY FAULK (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:FAULK
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 E LAMAR ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3737
Mailing Address - Country:US
Mailing Address - Phone:229-924-8636
Mailing Address - Fax:229-924-8786
Practice Address - Street 1:609 E LAMAR ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3737
Practice Address - Country:US
Practice Address - Phone:229-924-8636
Practice Address - Fax:229-924-8786
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily