Healthcare Provider Details

I. General information

NPI: 1720616873
Provider Name (Legal Business Name): STEPHANIE ANN WILLIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE ANN BURNHAM RN

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

811 REDGATE AVE
NORFOLK VA
23507-1515
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-9222
  • Fax: 757-668-7568
Mailing address:
  • Phone: 757-668-7007
  • Fax: 757-668-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024179867
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001244829
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: