Provider Demographics
NPI:1801662234
Name:WILLIS, MIECHA Y
Entity type:Individual
Prefix:
First Name:MIECHA
Middle Name:Y
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 1:1415 HIGHWAY 85 N # 310-178
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7738
Mailing Address - Country:US
Mailing Address - Phone:404-944-3031
Mailing Address - Fax:
Practice Address - Street 1:1487 HIGHWAY 92 N
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-3323
Practice Address - Country:US
Practice Address - Phone:404-944-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician