Provider Demographics
NPI:1699330282
Name:WILLIS, COURTNEY S (FNP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:S
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 N GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7030
Mailing Address - Country:US
Mailing Address - Phone:276-525-0365
Mailing Address - Fax:
Practice Address - Street 1:2203 N GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7030
Practice Address - Country:US
Practice Address - Phone:276-525-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000025835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily