Provider Demographics
NPI:1821159039
Name:WILLIS, JUDITH LYNNE (MPH RD CD CDCES)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNNE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MPH RD CD CDCES
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:LYNNE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPH RD CD CDCES
Mailing Address - Street 1:20 UNIVERSITY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5815
Mailing Address - Country:US
Mailing Address - Phone:617-420-5858
Mailing Address - Fax:
Practice Address - Street 1:1114 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5204
Practice Address - Country:US
Practice Address - Phone:360-510-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001288133V00000X
WA727126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered