Provider Demographics
NPI:1356776975
Name:WILLIS, JEANINE R (CNP)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:R
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18099 LORAIN AVE STE 445
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5610
Mailing Address - Country:US
Mailing Address - Phone:440-886-1800
Mailing Address - Fax:
Practice Address - Street 1:18099 LORAIN AVE STE 445
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5610
Practice Address - Country:US
Practice Address - Phone:440-886-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15100-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096370Medicaid