Provider Demographics
NPI:1275380404
Name:WILLIS, DIANNE CUPIDO
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:CUPIDO
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 1:7201 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2913
Mailing Address - Country:US
Mailing Address - Phone:954-721-2200
Mailing Address - Fax:
Practice Address - Street 1:7201 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2913
Practice Address - Country:US
Practice Address - Phone:786-205-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027696363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care