Healthcare Provider Details

I. General information

NPI: 1548754757
Provider Name (Legal Business Name): MS. KAJUAN EMONIE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5834 MONROE ST STE 1201
SYLVANIA OH
43560-2267
US

IV. Provider business mailing address

5834 MONROE ST STE 1201 SUITE A
SYLVANIA OH
43560-2267
US

V. Phone/Fax

Practice location:
  • Phone: 567-318-2586
  • Fax: 419-299-6069
Mailing address:
  • Phone: 567-318-2586
  • Fax: 419-299-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE.2606359
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: