Provider Demographics
NPI:1134871775
Name:WILLIS, AMANDA (RN IBCLC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN IBCLC
Mailing Address - Street 1:1621 LAKEVILLE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2694
Mailing Address - Country:US
Mailing Address - Phone:281-305-0411
Mailing Address - Fax:281-572-0627
Practice Address - Street 1:1621 LAKEVILLE DR STE 304
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2694
Practice Address - Country:US
Practice Address - Phone:281-305-0411
Practice Address - Fax:281-572-0627
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAL-305357163WL0100X
TX780850163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant