Individual
TANYA WILLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CNNP
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 984-5260
Mailing address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 984-5260
Taxonomy
Speciality
Code
Description
License number
State
363LN0000X
Neonatal Nurse Practitioner
Primary
R851015
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07628760
—
MS
Enumeration date
06/28/2006
Last updated
06/14/2012
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