Provider Demographics
NPI:1518476688
Name:WILLIS, INDIA R (APN)
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:R
Last Name:WILLIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:INDIA
Other - Middle Name:RASHELL
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:4025 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2010
Mailing Address - Country:US
Mailing Address - Phone:773-388-1600
Mailing Address - Fax:773-388-1602
Practice Address - Street 1:1525 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5512
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-783-8197
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty