Provider Demographics
NPI:1386107688
Name:ILLUSTRISIMO, WILLA ESPINA (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:WILLA
Middle Name:ESPINA
Last Name:ILLUSTRISIMO
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CREEKSIDE DR STE 2700
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3485
Mailing Address - Country:US
Mailing Address - Phone:530-677-0700
Mailing Address - Fax:
Practice Address - Street 1:1600 CREEKSIDE DR STE 2700
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3485
Practice Address - Country:US
Practice Address - Phone:530-677-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95010024363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty