Provider Demographics
NPI:1366911927
Name:WILLIS, ANGELA SOYAD (NP-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:SOYAD
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15589 WINTERPARK DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3877
Mailing Address - Country:US
Mailing Address - Phone:586-872-7866
Mailing Address - Fax:
Practice Address - Street 1:43455 SCHOENHERR RD STE 2
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1972
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307286363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health