Provider Demographics
NPI:1316670631
Name:WILLIS, NISHAE LATRICE (CNA)
Entity type:Individual
Prefix:
First Name:NISHAE
Middle Name:LATRICE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:NISHAE
Other - Middle Name:LATRICE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:7315 ALBRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1228
Mailing Address - Country:US
Mailing Address - Phone:314-699-1166
Mailing Address - Fax:
Practice Address - Street 1:7315 ALBRIGHT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-1228
Practice Address - Country:US
Practice Address - Phone:314-699-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOV137105002172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver