Provider Demographics
NPI:1326585902
Name:WILLIS, GLEN (LPN)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 RUGBY PL APT B
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-5427
Mailing Address - Country:US
Mailing Address - Phone:631-627-9455
Mailing Address - Fax:
Practice Address - Street 1:1807 RUGBY PL APT B
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-5427
Practice Address - Country:US
Practice Address - Phone:631-627-9455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310633-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse