Healthcare Provider Details

I. General information

NPI: 1437741238
Provider Name (Legal Business Name): GENEVIEVE WILLIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GENEVIEVE HERINGTON

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 E MAIN ST
FARMINGTON NM
87402-8660
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6495
  • Fax:
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62794
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: