Provider Demographics
NPI:1427043983
Name:WILLIS, JENNIFER TRICIA (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:TRICIA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:TRICIA
Other - Last Name:BROLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2608 CREST VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094
Mailing Address - Country:US
Mailing Address - Phone:770-648-8237
Mailing Address - Fax:770-648-8237
Practice Address - Street 1:2608 CREST VALLEY DRIVE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:404-428-2237
Practice Address - Fax:404-428-2237
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA180459367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered