Basic Information
| Provider Information | |||||||||
| NPI: | 1174544761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 W ORCHARD DR | ||||||||
| Address2: | SUITE #4 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603188800 | ||||||||
| FaxNumber: | 3603181085 | ||||||||
| Practice Location | |||||||||
| Address1: | 2075 BARKLEY BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982266614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606713345 | ||||||||
| FaxNumber: | 3606501354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30000325 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 423898016 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 9602970 | 05 | WA | MEDICAID | 8925053 | 01 | WA | L & I (CRIME VICTIM) | OTHER | 192942512 | 01 | WA | US DEPT OF LABOR | OTHER | 0128742 | 01 | WA | L & I (REGULAR) | OTHER | 25892 | 01 | WA | REGENCE BLUESHIELD | OTHER | 0500013378 | 01 | WA | RAILROAD MEDICARE | OTHER |