Provider Demographics
NPI:1669016002
Name:WILLIS, ROSALYN MARIE
Entity Type:Individual
Prefix:MRS
First Name:ROSALYN
Middle Name:MARIE
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:PO BOX 1614
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423
Mailing Address - Country:US
Mailing Address - Phone:837-659-9844
Mailing Address - Fax:
Practice Address - Street 1:4826 11TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423
Practice Address - Country:US
Practice Address - Phone:832-659-9844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider