Healthcare Provider Details

I. General information

NPI: 1285249474
Provider Name (Legal Business Name): KATHRYN SUE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 PERCENTUM RD APT 311
TOLEDO OH
43617-2141
US

IV. Provider business mailing address

3316 PERCENTUM RD APT 311
TOLEDO OH
43617-2141
US

V. Phone/Fax

Practice location:
  • Phone: 419-283-3260
  • Fax:
Mailing address:
  • Phone: 419-283-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number4808328
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number4808328
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number4808328
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: