Provider Demographics
NPI:1710953559
Name:WILLIS, DANINE THERESA (ARNP)
Entity Type:Individual
Prefix:MS
First Name:DANINE
Middle Name:THERESA
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 1:2216 E 32ND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3015
Mailing Address - Country:US
Mailing Address - Phone:417-556-2780
Mailing Address - Fax:
Practice Address - Street 1:2216 E 32ND ST STE 101
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3015
Practice Address - Country:US
Practice Address - Phone:417-556-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44929363L00000X
ARA004899363L00000X
MO2004033676363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100352890CMedicaid
KS100352890CMedicaid
KS161506Medicare ID - Type Unspecified