Healthcare Provider Details

I. General information

NPI: 1235779620
Provider Name (Legal Business Name): AISHA S HAVILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 07/01/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 ROGER POWELL RD
SEBREE KY
42455-2115
US

IV. Provider business mailing address

PO BOX 269084 DEPT 1102
OKLAHOMA CITY OK
73126
US

V. Phone/Fax

Practice location:
  • Phone: 731-394-1145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009776A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4038094
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: