Provider Demographics
NPI:1447323597
Name:WILLIS, DEON TYWONN (MPH)
Entity type:Individual
Prefix:MISS
First Name:DEON
Middle Name:TYWONN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 THURMAN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1648
Mailing Address - Country:US
Mailing Address - Phone:770-775-5861
Mailing Address - Fax:770-233-5503
Practice Address - Street 1:315 S 9TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4111
Practice Address - Country:US
Practice Address - Phone:770-229-3048
Practice Address - Fax:770-233-5503
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator