Healthcare Provider Details

I. General information

NPI: 1972259497
Provider Name (Legal Business Name): KAYLEIGH KESHIA WILLIAMS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3713 BENSON DR STE 201
RALEIGH NC
27609-7372
US

IV. Provider business mailing address

PO BOX 603949
CHARLOTTE NC
28260-3949
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6520
  • Fax:
Mailing address:
  • Phone: 919-350-8991
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11929
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-11929
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: