Provider Demographics
NPI:1225235005
Name:WILLIS, LATANYA MARIA (FNP)
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:MARIA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12324 N 144TH DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-4477
Mailing Address - Country:US
Mailing Address - Phone:216-798-3926
Mailing Address - Fax:
Practice Address - Street 1:9675 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3667
Practice Address - Country:US
Practice Address - Phone:844-646-3247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH330479163WP0200X, 163WM0705X
TX832010363LF0000X
AZAP8888363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical