Provider Demographics
NPI:1720579311
Name:WILLIS, ADRIENNE DANIELLE (ATC)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:DANIELLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7248 KELVIN AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-2766
Mailing Address - Country:US
Mailing Address - Phone:818-389-1336
Mailing Address - Fax:
Practice Address - Street 1:18111 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330-0001
Practice Address - Country:US
Practice Address - Phone:818-677-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-20
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program