Provider Demographics
NPI:1689340515
Name:WILLIS, TYLER (DNP, NP)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DNP, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9635
Mailing Address - Country:US
Mailing Address - Phone:901-428-9900
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-678-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61540212363L00000X, 363LA2100X
TN29874363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner