Provider Demographics
NPI:1578162681
Name:WILLIS, DESHEA
Entity Type:Individual
Prefix:
First Name:DESHEA
Middle Name:
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 1:21150 N TATUM BLVD APT 3049
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21150 N TATUM BLVD APT 3049
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7238
Practice Address - Country:US
Practice Address - Phone:513-223-1279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health