Healthcare Provider Details

I. General information

NPI: 1437350527
Provider Name (Legal Business Name): KANYE WILLIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 BOULEVARD NE SUITE 555
ATLANTA GA
30312-1200
US

IV. Provider business mailing address

315 BOULEVARD NE SUITE 555
ATLANTA GA
30312-1200
US

V. Phone/Fax

Practice location:
  • Phone: 404-265-4000
  • Fax:
Mailing address:
  • Phone: 404-265-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number64699
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number64699
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: