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General NPI Number Information
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NPI Number | 1144746959
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Entity Type | Individual
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Provider Name | ERIN WILLIS
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Gender | Female
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Dates
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Enumeration Date | 08/15/2017
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Last Update Date | 08/15/2017
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Provider Practice Location Address
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Address Line | 4401 N MAIN ST
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City | ROCKFORD
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State | IL
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Zip | 61103-1277
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Country | US
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Telephone | 815-921-9200
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Fax |
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Provider Business Mailing Address
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Address Line | 95 GRANT ST APT 1
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-4330
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Country | US
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Telephone | 317-531-1697
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 242.004526
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License Number State | IL
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