Healthcare Provider Details

I. General information

NPI: 1588508659
Provider Name (Legal Business Name): SHERI R WILLIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 TIMBERWALK CT
LA GRANGE KY
40031-6746
US

IV. Provider business mailing address

504 GRASMERE DR
CLARKSVILLE IN
47129-1922
US

V. Phone/Fax

Practice location:
  • Phone: 703-864-6695
  • Fax:
Mailing address:
  • Phone: 502-974-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA04762
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: