Provider Demographics
NPI:1003651886
Name:WILLIS, LYDELL
Entity type:Individual
Prefix:MR
First Name:LYDELL
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 1:80 N PORTAGE PATH APT 14A8
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44303-2526
Mailing Address - Country:US
Mailing Address - Phone:702-354-4865
Mailing Address - Fax:
Practice Address - Street 1:80 N PORTAGE PATH APT 14A8
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44303-2526
Practice Address - Country:US
Practice Address - Phone:702-354-4865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide