=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336544758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. LINDSEY NICOLE WILLIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2014
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 SW H K DODGEN LOOP
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-298-2689
-----------------------------------------------------
Fax | 254-778-7196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2411 W ELM MOTT DR
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76705-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-717-3998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | AP126723
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------