Provider Demographics
NPI:1104109396
Name:WILLIS, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:HANNAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 N. COLLEGE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 N. COLLEGE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11267183500000X
AZ15672183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist