Healthcare Provider Details

I. General information

NPI: 1467173500
Provider Name (Legal Business Name): CAITLYN WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 GEORGE ST
BECKLEY WV
25801-2641
US

IV. Provider business mailing address

110 SANDSTONE DR
BECKLEY WV
25801-2822
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-0620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: