Provider Demographics
NPI:1891248985
Name:WILLIS, RACHEL GRACE RENEE (RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:GRACE RENEE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:MRS
Other - First Name:RACHEL
Other - Middle Name:GRACE RENEE
Other - Last Name:MATHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2076 BROOKBANK DR
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4733
Mailing Address - Country:US
Mailing Address - Phone:269-601-1186
Mailing Address - Fax:
Practice Address - Street 1:5838 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9619
Practice Address - Country:US
Practice Address - Phone:616-249-5300
Practice Address - Fax:616-249-5341
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10362133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered