Provider Demographics
NPI:1235546433
Name:WILLOUGHBY, KENYATTA
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:WILLOUGHBY
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 1:2994 SANDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-6827
Mailing Address - Country:US
Mailing Address - Phone:614-607-8629
Mailing Address - Fax:
Practice Address - Street 1:2994 SANDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-6827
Practice Address - Country:US
Practice Address - Phone:614-607-8629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-20
Last Update Date:2014-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2771460172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163WHO200XMedicaid