Provider Demographics
NPI:1649560939
Name:WILLIS, KATHERINE BROOKE (LAC, MAOM)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BROOKE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-602-8172
Mailing Address - Fax:
Practice Address - Street 1:426 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-602-8172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR153659171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist