Provider Demographics
NPI:1114349313
Name:WILLINGHAM, MCKINLEY
Entity Type:Individual
Prefix:
First Name:MCKINLEY
Middle Name:
Last Name:WILLINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8295 TOURNAMENT DR
Mailing Address - Street 2:150
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8906
Mailing Address - Country:US
Mailing Address - Phone:866-563-7772
Mailing Address - Fax:901-255-0758
Practice Address - Street 1:6821 RALEIGH LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-7031
Practice Address - Country:US
Practice Address - Phone:866-563-7772
Practice Address - Fax:901-255-0758
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14090164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse