Provider Demographics
NPI:1568813830
Name:WILLIS, CRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:GOINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:253 RODDY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:TN
Mailing Address - Zip Code:37853-3108
Mailing Address - Country:US
Mailing Address - Phone:865-617-5654
Mailing Address - Fax:
Practice Address - Street 1:253 RODDY BRANCH RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:TN
Practice Address - Zip Code:37853-3108
Practice Address - Country:US
Practice Address - Phone:865-617-5654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000082566164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse