Provider Demographics
NPI:1649679515
Name:WILLIS, JOANNA (LAC)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:C-21
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:C-21
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-922-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-17
Last Update Date:2014-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1730171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist