Provider Demographics
NPI:1376899294
Name:WILLIS, TERESIA
Entity Type:Individual
Prefix:
First Name:TERESIA
Middle Name:
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 1:1628 KENSINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6414
Mailing Address - Country:US
Mailing Address - Phone:513-435-1661
Mailing Address - Fax:
Practice Address - Street 1:1628 KENSINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6414
Practice Address - Country:US
Practice Address - Phone:513-435-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-29
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137788164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse