Basic Information
| Provider Information | |||||||||
| NPI: | 1316303571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | CHRISTIN | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.D.,L.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIS | ||||||||
| OtherFirstName: | CHRISSY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6908 N 440 RD | ||||||||
| Address2: | |||||||||
| City: | ADAIR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743303129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182564800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 27371 S 4410 RD | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743017953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182564800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2016 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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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 | 133V00000X | 2060 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.