Healthcare Provider Details

I. General information

NPI: 1245623438
Provider Name (Legal Business Name): LENA OLIVIA WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6144 SMITHFIELD DR
TROY MI
48085-1080
US

IV. Provider business mailing address

6144 SMITHFIELD DR
TROY MI
48085-1080
US

V. Phone/Fax

Practice location:
  • Phone: 313-646-8347
  • Fax:
Mailing address:
  • Phone: 313-646-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: