Provider Demographics
NPI:1598298176
Name:WILLIS, CHELSEA DAWN
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:DAWN
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 1:6675 HOLMES RD STE 360
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1167
Mailing Address - Country:US
Mailing Address - Phone:816-276-7600
Mailing Address - Fax:816-276-7992
Practice Address - Street 1:410 WOODFIELD DR
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-5443
Practice Address - Country:US
Practice Address - Phone:913-845-8400
Practice Address - Fax:785-505-5272
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS0542913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program