Provider Demographics
NPI:1215078845
Name:WILLIS, SAUNDRA RENEE (PT)
Entity type:Individual
Prefix:MISS
First Name:SAUNDRA
Middle Name:RENEE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-0004
Mailing Address - Country:US
Mailing Address - Phone:662-840-2888
Mailing Address - Fax:662-840-4245
Practice Address - Street 1:1893 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-5953
Practice Address - Country:US
Practice Address - Phone:662-840-2888
Practice Address - Fax:662-840-4245
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02439Medicare UPIN
MS650000042Medicare ID - Type Unspecified