Provider Demographics
NPI:1912263914
Name:WILLIS, TONIA ANITRA (C-NP)
Entity Type:Individual
Prefix:MS
First Name:TONIA
Middle Name:ANITRA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:C-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14102 SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227
Mailing Address - Country:US
Mailing Address - Phone:313-673-8076
Mailing Address - Fax:
Practice Address - Street 1:14102 SAINT MARYS ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227
Practice Address - Country:US
Practice Address - Phone:313-673-8076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249744363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care