Healthcare Provider Details

I. General information

NPI: 1083817969
Provider Name (Legal Business Name): ELIZABETH REAVES WILLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 HEARNE AVE SUITE 300
SHREVEPORT LA
71103-3917
US

IV. Provider business mailing address

PO BOX 51008
SHREVEPORT LA
71135-1008
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-9400
  • Fax: 318-798-3894
Mailing address:
  • Phone: 318-798-9400
  • Fax: 318-798-3894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP03281
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: