Healthcare Provider Details

I. General information

NPI: 1558063156
Provider Name (Legal Business Name): EMILY DAVADA WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11087 MAIN ST
MARTIN KY
41649-7999
US

IV. Provider business mailing address

11087 MAIN ST
MARTIN KY
41649-7999
US

V. Phone/Fax

Practice location:
  • Phone: 304-424-4575
  • Fax: 304-424-4577
Mailing address:
  • Phone: 304-424-4575
  • Fax: 304-424-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number06428
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: