Provider Demographics
NPI:1609325166
Name:WILLIS, PAULA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 GRAYS HWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-4419
Mailing Address - Country:US
Mailing Address - Phone:843-726-7788
Mailing Address - Fax:843-726-5320
Practice Address - Street 1:651 GRAYS HWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-5488
Practice Address - Country:US
Practice Address - Phone:843-726-7788
Practice Address - Fax:843-726-5320
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP15908164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse