Provider Demographics
NPI:1770047557
Name:WILLIS, MICHELLE RENE (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:KS
Mailing Address - Zip Code:67356-2101
Mailing Address - Country:US
Mailing Address - Phone:620-423-4266
Mailing Address - Fax:
Practice Address - Street 1:3901 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3312
Practice Address - Country:US
Practice Address - Phone:417-347-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78546-122363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health