Provider Demographics
NPI:1831509066
Name:WILLIS, ROXANNE M
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:M
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:PO BOX 1133
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83869-1133
Mailing Address - Country:US
Mailing Address - Phone:208-651-2298
Mailing Address - Fax:208-623-6717
Practice Address - Street 1:6186 W MAINE ST.
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:ID
Practice Address - Zip Code:83869
Practice Address - Country:US
Practice Address - Phone:208-651-2298
Practice Address - Fax:208-623-6717
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-13225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist