Healthcare Provider Details

I. General information

NPI: 1073022737
Provider Name (Legal Business Name): MRS. KAYLA CHILDRESS WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

249 FIELDSTONE LN
MADISON MS
39110-5051
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-2001
  • Fax:
Mailing address:
  • Phone: 601-618-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number902339
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: