Provider Demographics
NPI:1760929053
Name:WILLIS, GENNICE JENAIL
Entity Type:Individual
Prefix:
First Name:GENNICE
Middle Name:JENAIL
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 1:12017 DAHOON DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8131
Mailing Address - Country:US
Mailing Address - Phone:405-313-8685
Mailing Address - Fax:877-719-2739
Practice Address - Street 1:12017 DAHOON DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8131
Practice Address - Country:US
Practice Address - Phone:405-313-8685
Practice Address - Fax:877-719-2739
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37H041801211251J00000X, 376K00000X
OK37V261041204253Z00000X, 374U00000X
NY37H041801211376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No376K00000XNursing Service Related ProvidersNurse's Aide