Provider Demographics
NPI:1508800772
Name:WILLIS, MINA SALAFRANCA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:SALAFRANCA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:NEPOMUCENO
Other - Last Name:SALAFRANCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 GOSS ROAD
Mailing Address - Street 2:
Mailing Address - City:REDSTONE ARSENAL
Mailing Address - State:AL
Mailing Address - Zip Code:35809-7000
Mailing Address - Country:US
Mailing Address - Phone:256-955-8888
Mailing Address - Fax:
Practice Address - Street 1:4100 GOSS RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35809-0001
Practice Address - Country:US
Practice Address - Phone:256-955-8888
Practice Address - Fax:256-955-0189
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101727363A00000X
VA0202207364183500000X
VA0110002299363A00000X, 363A00000X
FLPS35862183500000X
MDC0003325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9101727Medicaid
FLPA9101727Medicaid