MEDICARE: PATRICIA ANN WILLIS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	198463-3102	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	198463-3102	OTHER	UT	DOPL - REGISTERED NURSE

General Provider Information

NPI Number	:	1720250384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA ANN WILLIS RN

Provider Business Mailing Address
First Line	:	3458 WESTWOOD DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-3239
Country	:	US
Telephone Number	:	801-278-8975
Fax Number	:

Provider Business Practice Location Address
First Line	:	3458 WESTWOOD DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-3239
Country	:	US
Telephone Number	:	801-278-8975
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	03/24/2008

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