Provider Demographics
NPI:1154107654
Name:WILLIS, HALLIE JEAN (FNP-C)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:JEAN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:HALLIE
Other - Middle Name:
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:867 NINE SPRINGS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MACKS CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65786-7702
Mailing Address - Country:US
Mailing Address - Phone:573-378-3182
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023036914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily