Provider Demographics
NPI:1114514833
Name:WILLIS, AMY BRUTSCHER (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BRUTSCHER
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 MOUNT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1004
Mailing Address - Country:US
Mailing Address - Phone:502-380-6823
Mailing Address - Fax:
Practice Address - Street 1:4509 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1004
Practice Address - Country:US
Practice Address - Phone:502-380-6823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015544363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care