Provider Demographics
NPI:1689928855
Name:WILLIS, ESTELLA E (LPN)
Entity Type:Individual
Prefix:
First Name:ESTELLA
Middle Name:E
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-3860
Mailing Address - Country:US
Mailing Address - Phone:440-381-0729
Mailing Address - Fax:
Practice Address - Street 1:919 W 20TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-3860
Practice Address - Country:US
Practice Address - Phone:440-381-0729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150468164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse