Provider Demographics
NPI:1457744336
Name:WILLIS, LAJUANA MCQUEEN (RN)
Entity Type:Individual
Prefix:MRS
First Name:LAJUANA
Middle Name:MCQUEEN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:LAJUANA
Other - Middle Name:
Other - Last Name:MCQUEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:10710 CHARTER DR
Mailing Address - Street 2:#200
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3128
Mailing Address - Country:US
Mailing Address - Phone:410-884-8000
Mailing Address - Fax:410-997-6019
Practice Address - Street 1:10710 CHARTER DR
Practice Address - Street 2:#200
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3128
Practice Address - Country:US
Practice Address - Phone:410-884-8000
Practice Address - Fax:410-997-6019
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR171824163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory