Provider Demographics
NPI:1629379813
Name:WILLIS, DAWN ANNETTE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:ANNETTE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9020 COUNTRY DOWNS CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-8473
Mailing Address - Country:US
Mailing Address - Phone:901-745-7758
Mailing Address - Fax:
Practice Address - Street 1:9020 COUNTRY DOWNS CV
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-8473
Practice Address - Country:US
Practice Address - Phone:901-382-6383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT0000001276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNOT0000001276OtherSTATE LICENSURE NUMBER