Provider Demographics
NPI:1346499241
Name:WILLIS, MARY E (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 3RD ST
Mailing Address - Street 2:PO BOX 184
Mailing Address - City:WINCHESTER
Mailing Address - State:KS
Mailing Address - Zip Code:66097-4152
Mailing Address - Country:US
Mailing Address - Phone:913-774-2024
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1378828-102261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health