Provider Demographics
NPI:1972186880
Name:WILLIS, DEONNA G (APRN)
Entity Type:Individual
Prefix:MRS
First Name:DEONNA
Middle Name:G
Last Name:WILLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 NW HALL OF FAME DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4833
Mailing Address - Country:US
Mailing Address - Phone:386-719-2540
Mailing Address - Fax:386-752-9073
Practice Address - Street 1:404 NW HALL OF FAME DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4833
Practice Address - Country:US
Practice Address - Phone:386-719-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily