Provider Demographics
NPI:1487405452
Name:WILLIS, PEBBLES P (PSS)
Entity type:Individual
Prefix:
First Name:PEBBLES
Middle Name:P
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 DUNBARTON AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8216
Mailing Address - Country:US
Mailing Address - Phone:877-522-1275
Mailing Address - Fax:509-491-3031
Practice Address - Street 1:8050 W RIFLEMAN ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9006
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:509-491-3031
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist