Healthcare Provider Details

I. General information

NPI: 1346346335
Provider Name (Legal Business Name): WILLOW WELLNESS CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E FRONT ST
TYLER TX
75702-8326
US

IV. Provider business mailing address

820 E FRONT ST
TYLER TX
75702-8326
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-0602
  • Fax: 903-596-0620
Mailing address:
  • Phone: 903-596-0602
  • Fax: 903-596-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELA NELL SMITH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 903-596-0602