Provider Demographics
NPI:1639060171
Name:WILLIS, MICHELLE DIANE (APRN-CNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DIANE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DIANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4133 BLUE RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4043
Mailing Address - Country:US
Mailing Address - Phone:405-613-8538
Mailing Address - Fax:
Practice Address - Street 1:411 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-5862
Practice Address - Country:US
Practice Address - Phone:405-224-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK224385363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily