Provider Demographics
NPI:1548581812
Name:WILLIS, GINA (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 CHERTSEY LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8775
Mailing Address - Country:US
Mailing Address - Phone:904-610-4462
Mailing Address - Fax:
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:SUITE 513
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-610-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29301225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist