Provider Demographics
NPI:1417092735
Name:WILLIS, VICKIE J (DC)
Entity Type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588-0048
Mailing Address - Country:US
Mailing Address - Phone:907-822-3353
Mailing Address - Fax:800-316-8024
Practice Address - Street 1:MILE 187.5 GLENN HWY
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588-0048
Practice Address - Country:US
Practice Address - Phone:907-822-3353
Practice Address - Fax:800-316-8024
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK162111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH0029Medicaid
AKCH0029Medicaid