Healthcare Provider Details

I. General information

NPI: 1699365551
Provider Name (Legal Business Name): KAYLA MONAE WILLETT SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 E BUTLER AVE APT 406263
MEMPHIS TN
38126-2513
US

IV. Provider business mailing address

263 E BUTLER AVE APT 406263
MEMPHIS TN
38126-2513
US

V. Phone/Fax

Practice location:
  • Phone: 901-264-5363
  • Fax:
Mailing address:
  • Phone: 901-264-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number191642
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: