Provider Demographics
NPI:1306952932
Name:WILLIS, LA JUANA DELL (CFNP)
Entity type:Individual
Prefix:MRS
First Name:LA JUANA
Middle Name:DELL
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:600 GALLEGOS
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:NM
Practice Address - Zip Code:88426-7602
Practice Address - Country:US
Practice Address - Phone:575-487-9000
Practice Address - Fax:575-487-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00145363L00000X
NMR14626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty