Healthcare Provider Details

I. General information

NPI: 1275462848
Provider Name (Legal Business Name): TIFFANY WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5322 S KIMBARK AVE APT 1N
CHICAGO IL
60615-5232
US

IV. Provider business mailing address

5322 S KIMBARK AVE APT 1N
CHICAGO IL
60615-5232
US

V. Phone/Fax

Practice location:
  • Phone: 312-363-9869
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.472068
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: