Provider Demographics
NPI:1679523971
Name:WILLIS WELCH, LEANN JEAN (NP)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:JEAN
Last Name:WILLIS WELCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3190
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0407
Mailing Address - Country:US
Mailing Address - Phone:541-888-9414
Mailing Address - Fax:541-888-5556
Practice Address - Street 1:630 MILUK DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-7728
Practice Address - Country:US
Practice Address - Phone:541-888-9414
Practice Address - Fax:541-888-5556
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200640863RN363LF0000X
OR200650049NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107658OtherMEDICARE ID# PTAN
OR240703Medicaid
ORMW1412927OtherCSR
OR165031Medicaid
OR165031Medicaid
381902Medicare Oscar/Certification
ORQ73896Medicare UPIN
OR213342Medicaid
200680007DPOtherDEA