Provider Demographics
NPI:1285857946
Name:WILLIS, LINDA J
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:GALBERTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1636 N 125TH LANE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323
Mailing Address - Country:US
Mailing Address - Phone:623-535-8078
Mailing Address - Fax:623-535-8078
Practice Address - Street 1:1636 N 125TH LANE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-535-8078
Practice Address - Fax:623-535-8078
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor