Provider Demographics
NPI:1942052519
Name:WILLIS, TERRY LYNN
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LYNN
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 1:450 MT GURNEY LN
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8660
Mailing Address - Country:US
Mailing Address - Phone:541-670-1274
Mailing Address - Fax:
Practice Address - Street 1:450 MT GURNEY LN
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8660
Practice Address - Country:US
Practice Address - Phone:541-670-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider