Provider Demographics
NPI:1710127626
Name:WILLIS, MARY E (RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RD, LD, CDE
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 741331
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1331
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:913-338-1311
Practice Address - Street 1:15101 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:KS
Practice Address - Zip Code:66223-3154
Practice Address - Country:US
Practice Address - Phone:913-681-8866
Practice Address - Fax:913-338-1311
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered