Healthcare Provider Details

I. General information

NPI: 1649789025
Provider Name (Legal Business Name): REBECCA CHARLENE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FORT WASHAKIE HEALT CENTER LAB IHS 29 BLACK COAL DRIVE
FORT WASHAKIE WY
82514
US

IV. Provider business mailing address

811 E ADAMS AVE APT 5
RIVERTON WY
82501-4755
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7672
  • Fax:
Mailing address:
  • Phone:
  • 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: