Provider Demographics
NPI:1083958334
Name:WILLIS, TAMMY ANNETTE (OTA/L)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:ANNETTE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 OLD KEELON GAP RD
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:AL
Mailing Address - Zip Code:35585-4416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 JOHN ALDRIDGE DR
Practice Address - Street 2:
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674-3000
Practice Address - Country:US
Practice Address - Phone:256-383-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2667224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant