Provider Demographics
NPI:1295701266
Name:WILLIS, KERRY C (CRNP)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:C
Last Name:WILLIS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17967-9409
Mailing Address - Country:US
Mailing Address - Phone:570-578-6174
Mailing Address - Fax:
Practice Address - Street 1:57 W JUNIPER ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6410
Practice Address - Country:US
Practice Address - Phone:570-501-1017
Practice Address - Fax:570-501-2695
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP007004B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA053739QNJMedicare ID - Type Unspecified
PAP47746Medicare UPIN