Basic Information
| Provider Information | |||||||||
| NPI: | 1710127626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | R.D., L.D., C.D.E. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741331 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134690503 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Practice Location | |||||||||
| Address1: | 15101 GLENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662233154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136818866 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2009 | ||||||||
| LastUpdateDate: | 01/08/2013 | ||||||||
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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 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.