1649712019 NPI number — MRS. DAVONNA MARIE WILLIS ATC, LMT

Table of content: MRS. DAVONNA MARIE WILLIS ATC, LMT (NPI 1649712019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649712019 NPI number — MRS. DAVONNA MARIE WILLIS ATC, LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
DAVONNA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ATC, LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649712019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 N GILBERT RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85234-3398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-779-0744
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 N GILBERT RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-3398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-779-0744
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MT-12710 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com