Provider Demographics
NPI:1629498811
Name:WILLIS, NADINE JOSEPH (LVN)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:JOSEPH
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2426 DESERT OAK DR
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7514
Mailing Address - Country:US
Mailing Address - Phone:661-341-2000
Mailing Address - Fax:
Practice Address - Street 1:2426 DESERT OAK DR
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7514
Practice Address - Country:US
Practice Address - Phone:661-341-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-26
Last Update Date:2014-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN179986164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6423608OtherKAISER PERMENTE