Provider Demographics
NPI:1326589680
Name:WILLIS, AMBER DAWN (APN-BC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13240 E SMITH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8857
Mailing Address - Country:US
Mailing Address - Phone:618-315-9925
Mailing Address - Fax:
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:618-899-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-19
Last Update Date:2017-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015277363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily