Provider Demographics
NPI:1689129280
Name:WILLIS, RENITA C
Entity Type:Individual
Prefix:MRS
First Name:RENITA
Middle Name:C
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 1:2656 VILLAGE GREEN DR
Mailing Address - Street 2:APT B3
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4203
Mailing Address - Country:US
Mailing Address - Phone:630-352-1116
Mailing Address - Fax:
Practice Address - Street 1:2656 VILLAGE GREEN DR
Practice Address - Street 2:APT B3
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4203
Practice Address - Country:US
Practice Address - Phone:630-352-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program