Healthcare Provider Details

I. General information

NPI: 1093544827
Provider Name (Legal Business Name): AMBER WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 ROSS CLARK CIR
DOTHAN AL
36301-4765
US

IV. Provider business mailing address

1118 ROSS CLARK CIR STE 700
DOTHAN AL
36301-3043
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-5105
  • Fax:
Mailing address:
  • Phone: 334-793-5105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3-002594
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: