Healthcare Provider Details

I. General information

NPI: 1073908281
Provider Name (Legal Business Name): JACQUELINE EVA WILLIS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE EVA WILLIS NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 BARBARA LOOP SE SUITE D
RIO RANCHO NM
87124-1009
US

IV. Provider business mailing address

4101 BARBARA LOOP SE SUITE D
RIO RANCHO NM
87124-1009
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-6348
  • Fax:
Mailing address:
  • Phone: 505-892-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP02617
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: