Provider Demographics
NPI:1619046174
Name:WILLE, PHYLLIS DIANE (NP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:DIANE
Last Name:WILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK AVE.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:CARDIOVASCULAR AND THORACIC SURGERY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-904-7000
Practice Address - Fax:217-904-7742
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005442363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3270183Medicare PIN
IL6447860011Medicare NSC