Provider Demographics
NPI:1619415742
Name:WILLIS, EARLENE FAY
Entity Type:Individual
Prefix:MS
First Name:EARLENE
Middle Name:FAY
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 1:713 WAYCROSS RD APT A
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3288
Mailing Address - Country:US
Mailing Address - Phone:513-557-1048
Mailing Address - Fax:
Practice Address - Street 1:713 WAYCROSS RD APT A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3288
Practice Address - Country:US
Practice Address - Phone:513-557-1048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104497001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2654908Medicaid