Provider Demographics
NPI:1306904412
Name:WILLIS, REGINA RENEE (NP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:RENEE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 SHED RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5584
Mailing Address - Country:US
Mailing Address - Phone:318-741-5858
Mailing Address - Fax:318-741-4496
Practice Address - Street 1:5015 SHED RD STE 500
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5587
Practice Address - Country:US
Practice Address - Phone:318-741-5858
Practice Address - Fax:318-741-4496
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN054611363LA2100X
LAAP05016363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care