| Willow Wellness Center, P.a. | |
|
820 E Front St Tyler TX 75702-8326 | |
| (903) 596-0602 | |
| (903) 596-0620 |
| Full Name | Willow Wellness Center, P.a. |
|---|---|
| Speciality | Internal Medicine |
| Location | 820 E Front St, Tyler, Texas |
| Authorized Official Name and Position | Angela Nell Smith (PRESIDENT) |
| Authorized Official Contact | 9035960602 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Willow Wellness Center, P.a. 820 E Front St Tyler TX 75702-8326 Ph: (903) 596-0602 | Willow Wellness Center, P.a. 820 E Front St Tyler TX 75702-8326 Ph: (903) 596-0602 |
| NPI Number | 1346346335 |
|---|---|
| Provider Enumeration Date | 09/16/2006 |
| Last Update Date | 11/30/2011 |
| Medicare PECOS PAC ID | 7719085653 |
|---|---|
| Medicare Enrollment ID | O20070531000236 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1346346335 | NPI | - | NPPES |
| 031016101 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| 207RC0000X | Internal Medicine - Cardiovascular Disease | (* (Not Available)) | Secondary |
| Provider Name | Hattie E Henderson |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1407817489 PECOS PAC ID: 1951390541 Enrollment ID: I20040510000288 |
| Provider Name | Angela N Smith |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1740287838 PECOS PAC ID: 7113024225 Enrollment ID: I20070524000680 |
| Provider Name | Kimeshia N Johnson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1699928655 PECOS PAC ID: 0840321576 Enrollment ID: I20100624000578 |
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