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NPI Code Detail

MEDICARE: ALYSSA L.M. WILLIS CPNP-PC

MEDICARE: ALYSSA L.M. WILLIS CPNP-PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0200XPediatric Nurse PractitionerRN224983GA

General Provider Information

NPI Number : 1568030112
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALYSSA L.M. WILLIS CPNP-PC
Provider Business Mailing Address
First Line : 1654 FAIR OAK WAY
Second Line :
City : MABLETON
State : GA
Zip : 30126-5754
Country : US
Telephone Number : 228-238-1211
Fax Number :
Provider Business Practice Location Address
First Line : 450 NORTHSIDE CHEROKEE BLVD
Second Line :
City : CANTON
State : GA
Zip : 30115-8015
Country : US
Telephone Number : 770-224-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2021
Last Update Date : 01/29/2026

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