Healthcare Provider Details

I. General information

NPI: 1346830759
Provider Name (Legal Business Name): KAYLA MARIE WILLIAMS I HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 RIDGECREST RD
JACKSON TN
38305-2359
US

IV. Provider business mailing address

65 RIDGECREST RD
JACKSON TN
38305-2359
US

V. Phone/Fax

Practice location:
  • Phone: 731-668-6076
  • Fax: 731-668-7033
Mailing address:
  • Phone: 731-668-6076
  • Fax: 731-668-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number928
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: