Provider Demographics
NPI:1407331390
Name:WILLIS, CASSANDRA L
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6162 TEAGARDEN CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-3014
Mailing Address - Country:US
Mailing Address - Phone:937-951-9987
Mailing Address - Fax:
Practice Address - Street 1:6162 TEAGARDEN CIR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-3014
Practice Address - Country:US
Practice Address - Phone:937-951-9987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164301164W00000X
OHLPN.164302164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse