Healthcare Provider Details

I. General information

NPI: 1205100336
Provider Name (Legal Business Name): AMY WATSON WILLIS BS-ITFS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S RAILROAD AVE
DUNN NC
28334-4853
US

IV. Provider business mailing address

111 S RAILROAD AVE
DUNN NC
28334-4853
US

V. Phone/Fax

Practice location:
  • Phone: 910-892-0027
  • Fax: 910-892-0029
Mailing address:
  • Phone: 910-892-0027
  • Fax: 910-892-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: