Provider Demographics
NPI:1528259959
Name:WILLIS, LACANDA
Entity type:Individual
Prefix:MS
First Name:LACANDA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 E 53RD ST
Mailing Address - Street 2:SUITE 283
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4509
Mailing Address - Country:US
Mailing Address - Phone:773-837-4163
Mailing Address - Fax:708-798-2454
Practice Address - Street 1:1507 E 53RD ST
Practice Address - Street 2:SUITE 283
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4509
Practice Address - Country:US
Practice Address - Phone:773-837-4163
Practice Address - Fax:708-798-2454
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36435163002Medicaid