Provider Demographics
NPI:1518264589
Name:WILLIS, LINDA DIANE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DIANE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 WALKER RD
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-5427
Mailing Address - Country:US
Mailing Address - Phone:478-956-4790
Mailing Address - Fax:478-956-4790
Practice Address - Street 1:1341 WALKER RD
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-5427
Practice Address - Country:US
Practice Address - Phone:478-956-4790
Practice Address - Fax:478-956-4790
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111-R-0756376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide