Provider Demographics
NPI:1043028939
Name:WILLIS, PAYTON (NP)
Entity type:Individual
Prefix:MRS
First Name:PAYTON
Middle Name:
Last Name:WILLIS
Suffix:
Gender:
Credentials:NP
Other - Prefix:MISS
Other - First Name:PAYTON
Other - Middle Name:
Other - Last Name:TENNISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9877 OLD OLVEY RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-9391
Mailing Address - Country:US
Mailing Address - Phone:870-416-5797
Mailing Address - Fax:
Practice Address - Street 1:808 US-65
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601
Practice Address - Country:US
Practice Address - Phone:870-204-7263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-23
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR217530363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner