Provider Demographics
NPI:1942544952
Name:WILLIS, ANGELA SUE (LPN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:SUE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-4614
Mailing Address - Country:US
Mailing Address - Phone:515-263-0608
Mailing Address - Fax:
Practice Address - Street 1:500 3RD ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4614
Practice Address - Country:US
Practice Address - Phone:515-263-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP55915164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse