Healthcare Provider Details

I. General information

NPI: 1427155506
Provider Name (Legal Business Name): GRACE ROSELLE WILLIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 OLD FARM ROAD
BAKERSFIELD CA
93312-3402
US

IV. Provider business mailing address

3106 OLD FARM ROAD
BAKERSFIELD CA
93312-3402
US

V. Phone/Fax

Practice location:
  • Phone: 661-395-1835
  • Fax: 661-589-8311
Mailing address:
  • Phone: 661-395-1835
  • Fax: 661-589-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A5477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: