Healthcare Provider Details

I. General information

NPI: 1619431392
Provider Name (Legal Business Name): LYNDA MARIE WILLIS CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2019
Last Update Date: 01/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 PINEVIEW LN
FORT WORTH TX
76140-6505
US

IV. Provider business mailing address

608 PINEVIEW LN
FORT WORTH TX
76140-6505
US

V. Phone/Fax

Practice location:
  • Phone: 817-723-3294
  • Fax:
Mailing address:
  • Phone: 817-723-3294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number105276
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: