Provider Demographics
NPI:1407866221
Name:WILLIS, LYNN A (NP)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:A
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8526
Mailing Address - Fax:541-962-7479
Practice Address - Street 1:401 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1619
Practice Address - Country:US
Practice Address - Phone:541-786-8604
Practice Address - Fax:541-962-7479
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550083NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR831399009OtherREGENCE