Healthcare Provider Details

I. General information

NPI: 1790699106
Provider Name (Legal Business Name): KADEEN LATOYA WILLACEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 GILLIONVILLE RD
ALBANY GA
31707-3023
US

IV. Provider business mailing address

1240 HIGHWAY 54 W STE 408
FAYETTEVILLE GA
30214-4564
US

V. Phone/Fax

Practice location:
  • Phone: 720-499-4688
  • Fax:
Mailing address:
  • Phone: 720-499-4688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRN307343
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: