Provider Demographics
NPI:1639352339
Name:WILLIS, JOANNE LYTLE (ARNP)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:LYTLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-486-4005
Mailing Address - Fax:954-497-3857
Practice Address - Street 1:2900 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2519
Practice Address - Country:US
Practice Address - Phone:954-731-1000
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1837702363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health