Provider Demographics
NPI:1013010404
Name:WILLARD, KATHLEEN E (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 N SAN FRANCISCO ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-779-7840
Mailing Address - Fax:928-779-7895
Practice Address - Street 1:1150 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-779-7840
Practice Address - Fax:928-779-7895
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16295207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
107383Medicare ID - Type Unspecified
S37842Medicare UPIN