Provider Demographics
NPI:1922270958
Name:WILLIS, PHYLLIS LYNN (CRNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LYNN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MELBA DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3017
Mailing Address - Country:US
Mailing Address - Phone:334-794-6611
Mailing Address - Fax:334-794-6614
Practice Address - Street 1:1901 MELBA DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3017
Practice Address - Country:US
Practice Address - Phone:334-794-6611
Practice Address - Fax:334-794-6614
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1074431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily