Healthcare Provider Details

I. General information

NPI: 1538706619
Provider Name (Legal Business Name): KRISTIN NICOLE WILLIS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2019
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 COOPER POINT RD SW
OLYMPIA WA
98502-5736
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 360-486-6710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP144282
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: