Provider Demographics
NPI:1811281520
Name:WILLIS, KANDICE (PA-C)
Entity type:Individual
Prefix:
First Name:KANDICE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E PALATINE RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-5551
Mailing Address - Country:US
Mailing Address - Phone:847-776-1400
Mailing Address - Fax:847-776-1424
Practice Address - Street 1:909 E PALATINE RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-5551
Practice Address - Country:US
Practice Address - Phone:847-776-1400
Practice Address - Fax:847-776-1424
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001815363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400187296Medicare PIN