Provider Demographics
NPI:1609362912
Name:WILLIS, LINDA ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ANN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NEW SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2701
Mailing Address - Country:US
Mailing Address - Phone:518-453-2515
Mailing Address - Fax:518-453-2519
Practice Address - Street 1:30 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1410
Practice Address - Country:US
Practice Address - Phone:518-453-6750
Practice Address - Fax:518-453-6785
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY633827163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse