Provider Demographics
NPI:1386902682
Name:WILLIS, MELISSA SUE JAY
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:SUE JAY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:SUE
Other - Last Name:JAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:40020 PFP DERMATOLOGY
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1694
Mailing Address - Fax:319-356-0349
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:40020 PFP DERMATOLOGY
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-1694
Practice Address - Fax:319-356-0349
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR9424207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology