Provider Demographics
NPI:1205166899
Name:WILLIS, TINA H (MA, RD, CD)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:H
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MA, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 HARCOURT RD
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2074
Mailing Address - Country:US
Mailing Address - Phone:317-871-0000
Mailing Address - Fax:317-871-0010
Practice Address - Street 1:8402 HARCOURT RD
Practice Address - Street 2:STE 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2074
Practice Address - Country:US
Practice Address - Phone:317-871-0000
Practice Address - Fax:317-871-0010
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN875565133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered