Provider Demographics
NPI:1538417886
Name:WILLIS, QUATINA (LPN)
Entity type:Individual
Prefix:MRS
First Name:QUATINA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 KESWICK VILLAGE CT NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6523
Mailing Address - Country:US
Mailing Address - Phone:678-800-5091
Mailing Address - Fax:678-609-0592
Practice Address - Street 1:612 KESWICK VILLAGE CT NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6523
Practice Address - Country:US
Practice Address - Phone:678-281-4542
Practice Address - Fax:678-253-4118
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN066567164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse