Provider Demographics
NPI:1821334384
Name:WILLIS, CHANEL
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 S. JONES LV NV
Mailing Address - Street 2:
Mailing Address - City:NV
Mailing Address - State:NV
Mailing Address - Zip Code:89107
Mailing Address - Country:US
Mailing Address - Phone:702-822-1206
Mailing Address - Fax:702-822-1124
Practice Address - Street 1:224 S. JONES LV NV
Practice Address - Street 2:
Practice Address - City:NV
Practice Address - State:NV
Practice Address - Zip Code:89107
Practice Address - Country:US
Practice Address - Phone:702-822-1206
Practice Address - Fax:702-822-1124
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner