Provider Demographics
NPI:1851652986
Name:WILLEMS, ROISIN MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:ROISIN
Middle Name:MICHELLE
Last Name:WILLEMS
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 1:732 OLD DOCK RD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-1105
Mailing Address - Country:US
Mailing Address - Phone:631-269-2124
Mailing Address - Fax:
Practice Address - Street 1:732 OLD DOCK RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-1105
Practice Address - Country:US
Practice Address - Phone:631-269-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist