Provider Demographics
NPI:1538646914
Name:WILLOUGHBY, LOURDES FELISA (BA, QMHP, SF)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:FELISA
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:BA, QMHP, SF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-5296
Mailing Address - Country:US
Mailing Address - Phone:804-824-2300
Mailing Address - Fax:804-824-2300
Practice Address - Street 1:8180 HAMILTON DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5296
Practice Address - Country:US
Practice Address - Phone:804-824-2300
Practice Address - Fax:804-824-2300
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12VAC30-120-730372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion