Provider Demographics
NPI:1285474833
Name:WILLIS, DIAMOND MAE
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:MAE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 S STATE AVE STE 344
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-3828
Mailing Address - Country:US
Mailing Address - Phone:219-312-1762
Mailing Address - Fax:
Practice Address - Street 1:55 S STATE AVE STE 344
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-3828
Practice Address - Country:US
Practice Address - Phone:219-312-1762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care