Provider Demographics
NPI:1700188232
Name:WILLIS, WENDY SUMMER (DPM)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:SUMMER
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 SEVENTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701
Mailing Address - Country:US
Mailing Address - Phone:229-883-3535
Mailing Address - Fax:229-883-3783
Practice Address - Street 1:531 SEVENTH AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701
Practice Address - Country:US
Practice Address - Phone:229-883-3535
Practice Address - Fax:229-883-3783
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00306213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I489616OtherMEDICARE PTAN