Basic Information
| Provider Information | |||||||||
| NPI: | 1215581491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | ANDREA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RCP,RRT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7300 S RAEFORD RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283046162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
| FaxNumber: | 9104825219 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 S RAEFORD RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283046162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2019 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | 7305 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
No ID Information.