Provider Demographics
NPI:1114413960
Name:LANDIS, JILL (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LANDIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ELAINE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:989 GRIZZLY RD
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26833-8717
Mailing Address - Country:US
Mailing Address - Phone:304-668-3329
Mailing Address - Fax:
Practice Address - Street 1:22347 NORTHWESTERN PIKE
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-6343
Practice Address - Country:US
Practice Address - Phone:304-538-2331
Practice Address - Fax:304-822-7665
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV53897363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner