Healthcare Provider Details

I. General information

NPI: 1760929053
Provider Name (Legal Business Name): GENNICE JENAIL WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12017 DAHOON DR
OKLAHOMA CITY OK
73120-8131
US

IV. Provider business mailing address

12017 DAHOON DR
OKLAHOMA CITY OK
73120-8131
US

V. Phone/Fax

Practice location:
  • Phone: 405-313-8685
  • Fax: 877-719-2739
Mailing address:
  • Phone: 405-313-8685
  • Fax: 877-719-2739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number37H041801211
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number37V261041204
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number37V261041204
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number37H041801211
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number37H041801211
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: