Healthcare Provider Details

I. General information

NPI: 1346304557
Provider Name (Legal Business Name): SUSAN E WILLIS RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 JENNINGS STATION RD
SAINT LOUIS MO
63121-3323
US

IV. Provider business mailing address

4000 JENNINGS STATION RD
SAINT LOUIS MO
63121-3323
US

V. Phone/Fax

Practice location:
  • Phone: 314-679-7826
  • Fax: 314-679-7876
Mailing address:
  • Phone: 314-679-7826
  • Fax: 314-679-7876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number069751
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: