Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 0024167014 | VA |
NPI | 1003035148 |
---|---|
Provider Name | Mrs. Mary Elizabeth O'boyle Willis |
First Address | Richmond, VA 23291-1734 |
Second Address | Richmond, VA 23298-5051 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2007 |
Last Update Date | 05/04/2017 |