Provider Demographics
NPI:1528605847
Name:WILLIS, CANDYCE
Entity Type:Individual
Prefix:
First Name:CANDYCE
Middle Name:
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 1:3636 EXECUTIVE CENTER DR STE G70
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1628
Mailing Address - Country:US
Mailing Address - Phone:512-371-9555
Mailing Address - Fax:512-367-5756
Practice Address - Street 1:3636 EXECUTIVE CENTER DR STE G70
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1628
Practice Address - Country:US
Practice Address - Phone:512-371-9555
Practice Address - Fax:512-367-5756
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX860008163W00000X
TXAP143520363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse