Provider Demographics
NPI:1780322644
Name:WILLIS, DUSTY MAHEALANI (LPN)
Entity type:Individual
Prefix:
First Name:DUSTY
Middle Name:MAHEALANI
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 VITALE AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-9208
Mailing Address - Country:US
Mailing Address - Phone:808-387-4705
Mailing Address - Fax:
Practice Address - Street 1:100 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1926
Practice Address - Country:US
Practice Address - Phone:702-332-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-21
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV835700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
HILPN-10376OtherHAWAII BOARD OF NURSING - PVL