Provider Demographics
NPI:1942929666
Name:WILLIS, MADELYN
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:
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 1:412 LAIR LN
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4222
Mailing Address - Country:US
Mailing Address - Phone:806-418-1326
Mailing Address - Fax:
Practice Address - Street 1:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Practice Address - Street 2:3600 N. GARFIELD
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705
Practice Address - Country:US
Practice Address - Phone:432-620-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program