Provider Demographics
NPI:1598267544
Name:WILLIS, SERITA DANIELLE
Entity Type:Individual
Prefix:
First Name:SERITA
Middle Name:DANIELLE
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 1:2557 WILLIE CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055-3310
Mailing Address - Country:US
Mailing Address - Phone:276-224-3518
Mailing Address - Fax:
Practice Address - Street 1:2557 WILLIE CRAIG ROAD
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055
Practice Address - Country:US
Practice Address - Phone:276-224-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63326190347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle