Provider Demographics
NPI:1477220077
Name:WILLIS, ELISSIA MARIE
Entity Type:Individual
Prefix:
First Name:ELISSIA
Middle Name:MARIE
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 1:25 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-2413
Mailing Address - Country:US
Mailing Address - Phone:614-403-0023
Mailing Address - Fax:
Practice Address - Street 1:25 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2413
Practice Address - Country:US
Practice Address - Phone:614-403-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program