Provider Demographics
NPI:1215422803
Name:WILLOUGHBY, DAVID JAMES
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 ANTELOPE TRL APT 146
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-3803
Mailing Address - Country:US
Mailing Address - Phone:254-541-3806
Mailing Address - Fax:
Practice Address - Street 1:13915 BURNET RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-6517
Practice Address - Country:US
Practice Address - Phone:512-996-9559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX151375164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse