Provider Demographics
NPI:1801032867
Name:WILLIS, CARRIE ANGELA (CRNA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANGELA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANGELA
Other - Last Name:DECKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34748
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40232-4748
Mailing Address - Country:US
Mailing Address - Phone:502-473-2132
Mailing Address - Fax:502-459-0923
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:LOUISVILLE
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-473-2132
Practice Address - Fax:502-459-0923
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005926367500000X
KY1096463163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse