Provider Demographics
NPI:1568030112
Name:WILLIS, ALYSSA LM (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LM
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 FAIR OAK WAY
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5754
Mailing Address - Country:US
Mailing Address - Phone:228-238-1211
Mailing Address - Fax:
Practice Address - Street 1:3911 MARY ELIZA TRCE NW STE 500
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1089
Practice Address - Country:US
Practice Address - Phone:678-384-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224983208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics