Basic Information
| Provider Information | |||||||||
| NPI: | 1457744336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | LAJUANA | ||||||||
| MiddleName: | MCQUEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCQUEEN | ||||||||
| OtherFirstName: | LAJUANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.N. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10710 CHARTER DR | ||||||||
| Address2: | #200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210443128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108848000 | ||||||||
| FaxNumber: | 4109976019 | ||||||||
| Practice Location | |||||||||
| Address1: | 10710 CHARTER DR | ||||||||
| Address2: | #200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210443128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108848000 | ||||||||
| FaxNumber: | 4109976019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2015 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | R171824 | MD | Y | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory |
No ID Information.