Provider Demographics
NPI:1750715819
Name:NORTHERN, WILLIE LEE
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:LEE
Last Name:NORTHERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N BUFFALO DR
Mailing Address - Street 2:STE 202
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0397
Mailing Address - Country:US
Mailing Address - Phone:702-527-7661
Mailing Address - Fax:702-527-7662
Practice Address - Street 1:401 N BUFFALO DR
Practice Address - Street 2:STE 202
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0397
Practice Address - Country:US
Practice Address - Phone:702-527-7661
Practice Address - Fax:702-527-7662
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner