Provider Demographics
NPI:1285096586
Name:WILLIS, ANDREA FRANCES (CORA/L)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:FRANCES
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CORA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 NELWOOD PL
Mailing Address - Street 2:
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-2161
Mailing Address - Country:US
Mailing Address - Phone:508-479-7747
Mailing Address - Fax:
Practice Address - Street 1:6800 LUCY CORR CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6657
Practice Address - Country:US
Practice Address - Phone:804-748-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001495224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant