Provider Demographics
NPI:1336544758
Name:WILLIS, LINDSEY NICOLE
Entity Type:Individual
Prefix:MS
First Name:LINDSEY
Middle Name:NICOLE
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 1:2411 W ELM MOTT DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-5304
Mailing Address - Country:US
Mailing Address - Phone:254-717-3998
Mailing Address - Fax:
Practice Address - Street 1:1905 SW H K DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1814
Practice Address - Country:US
Practice Address - Phone:254-298-2689
Practice Address - Fax:254-778-7196
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126723363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics