Provider Demographics
NPI:1669362299
Name:WILLIS, JAMIE LEANNE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEANNE
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 1:3890 SUNNY MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5008
Mailing Address - Country:US
Mailing Address - Phone:850-572-0604
Mailing Address - Fax:
Practice Address - Street 1:3890 SUNNY MANOR CIR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-5008
Practice Address - Country:US
Practice Address - Phone:850-572-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered