Healthcare Provider Details

I. General information

NPI: 1275831703
Provider Name (Legal Business Name): JOHN EVAN WILLIS CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SUN TEMPLE DR
MADISON AL
35758-5919
US

IV. Provider business mailing address

300 SUN TEMPLE DR
MADISON AL
35758-5919
US

V. Phone/Fax

Practice location:
  • Phone: 256-325-9111
  • Fax: 256-325-9113
Mailing address:
  • Phone: 256-325-9111
  • Fax: 256-325-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-114309
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: