Provider Demographics
NPI:1912223041
Name:WILLIS, CLARESSA FAY
Entity Type:Individual
Prefix:
First Name:CLARESSA
Middle Name:FAY
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 1:90-46 221ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428
Mailing Address - Country:US
Mailing Address - Phone:718-528-3432
Mailing Address - Fax:
Practice Address - Street 1:9046 221ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428
Practice Address - Country:US
Practice Address - Phone:718-528-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271519164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse