1326044587 NPI number — CHRISTIANNE M WILLIS PA

Table of content: CHRISTIANNE M WILLIS PA (NPI 1326044587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326044587 NPI number — CHRISTIANNE M WILLIS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
CHRISTIANNE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUENNEN
Provider Other First Name:
CHRISTIANNE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1326044587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 ASSOCIATES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52002-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-584-4100
Provider Business Mailing Address Fax Number:
563-584-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 S MADISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUBA CITY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53807-1154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-744-2115
Provider Business Practice Location Address Fax Number:
608-744-2117
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1391 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41957800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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