Healthcare Provider Details

I. General information

NPI: 1063472140
Provider Name (Legal Business Name): KATHLEEN H. WILLIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52579 HIGHWAY 51 S
INDEPENDENCE LA
70443-2231
US

IV. Provider business mailing address

PO BOX 65074
CHARLOTTE NC
28265-0074
US

V. Phone/Fax

Practice location:
  • Phone: 800-377-8721
  • Fax: 304-523-2241
Mailing address:
  • Phone: 800-377-8721
  • Fax: 304-523-2241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD024877
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: