Provider Demographics
NPI:1427155506
Name:WILLIS, GRACE ROSELLE (DO)
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:ROSELLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3106 OLD FARM ROAD
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-3402
Mailing Address - Country:US
Mailing Address - Phone:661-395-1835
Mailing Address - Fax:661-589-8311
Practice Address - Street 1:3106 OLD FARM ROAD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-3402
Practice Address - Country:US
Practice Address - Phone:661-395-1835
Practice Address - Fax:661-589-8311
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5477204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
F26601Medicare UPIN