Healthcare Provider Details

I. General information

NPI: 1811281520
Provider Name (Legal Business Name): KANDICE WILLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E PALATINE RD
PALATINE IL
60074-5551
US

IV. Provider business mailing address

909 E PALATINE RD
PALATINE IL
60074-5551
US

V. Phone/Fax

Practice location:
  • Phone: 847-776-1400
  • Fax: 847-776-1424
Mailing address:
  • Phone: 847-776-1400
  • Fax: 847-776-1424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085001815
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: