Provider Demographics
NPI:1760884936
Name:WILLIS, DIANA LYNN
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
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 1:1000 WALDEN CREEK CHASE
Mailing Address - Street 2:APT. 10-1C
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174
Mailing Address - Country:US
Mailing Address - Phone:615-893-2313
Mailing Address - Fax:
Practice Address - Street 1:1000 WALDEN CREEK CHASE
Practice Address - Street 2:APT. 10 1C
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174
Practice Address - Country:US
Practice Address - Phone:615-893-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist