Provider Demographics
NPI:1073908281
Name:WILLIS, JACQUELINE EVA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:EVA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:EVA
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:4101 BARBARA LOOP SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1009
Mailing Address - Country:US
Mailing Address - Phone:505-892-6348
Mailing Address - Fax:
Practice Address - Street 1:4101 BARBARA LOOP SE
Practice Address - Street 2:SUITE D
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1009
Practice Address - Country:US
Practice Address - Phone:505-892-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02617363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health