Provider Demographics
NPI:1306461660
Name:WILLIS, BRENDA LYNN (FNP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LYNN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7946 HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:PITKIN
Mailing Address - State:LA
Mailing Address - Zip Code:70656-4567
Mailing Address - Country:US
Mailing Address - Phone:337-208-1680
Mailing Address - Fax:
Practice Address - Street 1:908 S 10TH ST STE A
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4614
Practice Address - Country:US
Practice Address - Phone:337-392-2330
Practice Address - Fax:337-392-2580
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA213832363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily