Provider Demographics
NPI:1891771010
Name:WILLIS, CORRIE (RNBC, APMHCNS)
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RNBC, APMHCNS
Other - Prefix:
Other - First Name:CORRIE
Other - Middle Name:
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNBC, APMHCNS
Mailing Address - Street 1:303 WELLER ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-1942
Mailing Address - Country:US
Mailing Address - Phone:660-395-0180
Mailing Address - Fax:660-395-0181
Practice Address - Street 1:303 WELLER ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-1942
Practice Address - Country:US
Practice Address - Phone:660-395-0180
Practice Address - Fax:660-395-0181
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107534363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health