Healthcare Provider Details

I. General information

NPI: 1639612492
Provider Name (Legal Business Name): SUZIE L WILLIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 RIVERWALK PARK BLVD SUITE 100
FORT MYERS FL
33919-8758
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9960
  • Fax: 239-343-9977
Mailing address:
  • Phone: 239-343-9960
  • Fax: 239-343-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberAPRN3290832
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN3290832
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: