Provider Demographics
NPI:1396080396
Name:WILLIS, SUSAN DONNA (RN, FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DONNA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:DONNA
Other - Last Name:LEINWEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6608 MERCY CT STE C
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3171
Mailing Address - Country:US
Mailing Address - Phone:916-966-8585
Mailing Address - Fax:
Practice Address - Street 1:6608 MERCY CT STE C
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3171
Practice Address - Country:US
Practice Address - Phone:916-966-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-01
Last Update Date:2012-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily