Provider Demographics
NPI:1265209894
Name:WILLIS, DOROTHY
Entity type:Individual
Prefix:
First Name:DOROTHY
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 1:6086 HWY 98 W STE 3
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8804
Mailing Address - Country:US
Mailing Address - Phone:601-348-8452
Mailing Address - Fax:
Practice Address - Street 1:6086 HWY 98 W STE 3
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8804
Practice Address - Country:US
Practice Address - Phone:601-348-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant