Provider Demographics
NPI:1417550344
Name:WILLIS, BRIA
Entity Type:Individual
Prefix:
First Name:BRIA
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 1:187 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ATMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36502-1911
Mailing Address - Country:US
Mailing Address - Phone:251-525-1538
Mailing Address - Fax:
Practice Address - Street 1:187 BROAD ST
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-1911
Practice Address - Country:US
Practice Address - Phone:251-525-1538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program