Provider Demographics
NPI:1649789025
Name:WILLIS, REBECCA CHARLENE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:CHARLENE
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 1:811 E ADAMS AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FORT WASHAKIE HEALT CENTER LAB IHS 29 BLACK COAL DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-7672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid