Provider Demographics
NPI:1447905468
Name:WILLIS, AMIQUE AMOY
Entity type:Individual
Prefix:
First Name:AMIQUE
Middle Name:AMOY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3458
Mailing Address - Country:US
Mailing Address - Phone:188-835-1828
Mailing Address - Fax:
Practice Address - Street 1:4615 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3458
Practice Address - Country:US
Practice Address - Phone:188-835-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCUUI103212601OtherNORTH CAROLINA STUDENT BLUE