Provider Demographics
NPI:1497471684
Name:WILLIS, GRACE ELLEN
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:ELLEN
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 1:17142 JULIANA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3080
Mailing Address - Country:US
Mailing Address - Phone:313-989-5089
Mailing Address - Fax:
Practice Address - Street 1:17142 JULIANA AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3080
Practice Address - Country:US
Practice Address - Phone:313-989-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47030799496251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care