Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 20A5477 | CA |
NPI | 1427155506 |
---|---|
Provider Name | Ms. Grace Roselle Willis |
First Address | Bakersfield, CA 93312-3402 |
Second Address | Bakersfield, CA 93312-3402 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F26601 | (02) |