Provider Demographics
NPI:1164601514
Name:WILLIS, KIMBERLY Y (NP-C, BSN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:Y
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NP-C, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PERFORMANCE DR
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3104
Mailing Address - Country:US
Mailing Address - Phone:781-331-9091
Mailing Address - Fax:
Practice Address - Street 1:51 PERFORMANCE DR
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3104
Practice Address - Country:US
Practice Address - Phone:781-331-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232381363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner