Provider Demographics
NPI:1508374877
Name:WILLIS, MARGARET ANNE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:ANNE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:201 PARK ROW APT 208
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-2000
Mailing Address - Country:US
Mailing Address - Phone:909-680-0076
Mailing Address - Fax:
Practice Address - Street 1:800 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-1485
Practice Address - Country:US
Practice Address - Phone:909-680-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN34322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program