Provider Demographics
NPI:1720250384
Name:WILLIS, PATRICIA ANN (RN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3458 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3239
Mailing Address - Country:US
Mailing Address - Phone:801-278-8975
Mailing Address - Fax:
Practice Address - Street 1:3458 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-3239
Practice Address - Country:US
Practice Address - Phone:801-278-8975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT198463-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT198463-3102OtherDOPL - REGISTERED NURSE