Provider Demographics
NPI:1932196623
Name:WILLIS, WENDY (DC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 OAKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523-1611
Mailing Address - Country:US
Mailing Address - Phone:276-613-2729
Mailing Address - Fax:
Practice Address - Street 1:1508 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-2209
Practice Address - Country:US
Practice Address - Phone:540-583-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1157111N00000X
WV599111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350001034Medicare ID - Type Unspecified
U40546Medicare UPIN