Healthcare Provider Details

I. General information

NPI: 1194586768
Provider Name (Legal Business Name): DESTINY TAYLOR WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1764 LINDA AVE APT 2
MARYSVILLE CA
95901
US

IV. Provider business mailing address

990 KLAMATH LN STE 9
YUBA CITY CA
95993-8978
US

V. Phone/Fax

Practice location:
  • Phone: 530-649-4426
  • Fax:
Mailing address:
  • Phone: 916-413-4153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: