Healthcare Provider Details

I. General information

NPI: 1962961375
Provider Name (Legal Business Name): HANNAH MARIE WILLIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 07/16/2025
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE DIV IM PALLIATIVE MED, STE 241
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-5361
  • Fax: 314-747-5357
Mailing address:
  • Phone: 314-747-5361
  • Fax: 314-747-5357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2019003096
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: