Basic Information
| Provider Information | |||||||||
| NPI: | 1376162016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILLOUGHBY | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9454 MASON CREEK RD | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235033344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576460619 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3640 HIGH ST STE 3B | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573976344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2020 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.