Provider Demographics
NPI:1013607076
Name:WILLIE, PETER MICHAEL (BA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MICHAEL
Last Name:WILLIE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7412 ALEXIS LN
Mailing Address - Street 2:
Mailing Address - City:CAMBY
Mailing Address - State:IN
Mailing Address - Zip Code:46113-5524
Mailing Address - Country:US
Mailing Address - Phone:317-740-4181
Mailing Address - Fax:
Practice Address - Street 1:7412 ALEXIS LN
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-5524
Practice Address - Country:US
Practice Address - Phone:317-740-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider