Provider Demographics
NPI:1568175941
Name:WILLIS, SAMANTHA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12931 CARRINGTON PLACE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1205
Mailing Address - Country:US
Mailing Address - Phone:913-515-0300
Mailing Address - Fax:
Practice Address - Street 1:18448 MAGNOLIA BRIDGE RD STE A&B
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-4626
Practice Address - Country:US
Practice Address - Phone:225-256-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200411363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily