Provider Demographics
NPI:1164754305
Name:WILLIS, DELTA
Entity Type:Individual
Prefix:
First Name:DELTA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 SAINT NICHOLAS AVE
Mailing Address - Street 2:APT #3C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-1950
Mailing Address - Country:US
Mailing Address - Phone:646-283-3435
Mailing Address - Fax:
Practice Address - Street 1:832 SAINT NICHOLAS AVE
Practice Address - Street 2:APT #3C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-1950
Practice Address - Country:US
Practice Address - Phone:646-283-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY560987-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse