Healthcare Provider Details

I. General information

NPI: 1780549964
Provider Name (Legal Business Name): KIYANA WILLIS SW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 MULLIKIN CT
BALTIMORE MD
21231-1017
US

IV. Provider business mailing address

107 E 25TH ST
BALTIMORE MD
21218-5213
US

V. Phone/Fax

Practice location:
  • Phone: 667-352-8053
  • Fax:
Mailing address:
  • Phone: 410-558-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: