Provider Demographics
NPI:1649712019
Name:WILLIS, DAVONNA MARIE (ATC, LMT)
Entity type:Individual
Prefix:MRS
First Name:DAVONNA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N GILBERT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-3398
Mailing Address - Country:US
Mailing Address - Phone:480-779-0744
Mailing Address - Fax:
Practice Address - Street 1:625 N GILBERT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-3398
Practice Address - Country:US
Practice Address - Phone:480-779-0744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
AZMT-12710225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer