Provider Demographics
NPI:1083868350
Name:WILLIS, LINDA IRENE
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:IRENE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 BRADY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1614
Mailing Address - Country:US
Mailing Address - Phone:330-297-7663
Mailing Address - Fax:330-297-7663
Practice Address - Street 1:3102 BRADY LAKE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1614
Practice Address - Country:US
Practice Address - Phone:330-297-7663
Practice Address - Fax:330-297-7663
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide