Provider Demographics
NPI:1841507365
Name:WILLIS, MELANIE (DO)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 N CHINA LAKE BLVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3130
Mailing Address - Country:US
Mailing Address - Phone:760-499-3855
Mailing Address - Fax:760-499-3870
Practice Address - Street 1:1111 N CHINA LAKE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-499-3855
Practice Address - Fax:760-499-3870
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine