Provider Demographics
NPI:1770046807
Name:CHE, WILLYBROAD (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:WILLYBROAD
Middle Name:
Last Name:CHE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 LONG MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-0290
Mailing Address - Country:US
Mailing Address - Phone:469-286-8288
Mailing Address - Fax:
Practice Address - Street 1:1341 W MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6913
Practice Address - Country:US
Practice Address - Phone:972-630-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137559363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily