Provider Demographics
NPI:1063088250
Name:WILLIS, ABIGAIL (CRNA)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-1631
Mailing Address - Country:US
Mailing Address - Phone:304-972-3706
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV132344367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered