Provider Demographics
NPI:1346841350
Name:WILLIS, CHAVON (NP)
Entity Type:Individual
Prefix:
First Name:CHAVON
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25700 SCIENCE PARK DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7328
Mailing Address - Country:US
Mailing Address - Phone:216-450-1613
Mailing Address - Fax:
Practice Address - Street 1:25700 SCIENCE PARK DR STE 210
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7328
Practice Address - Country:US
Practice Address - Phone:216-450-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030202363LP0808X, 363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health