Provider Demographics
NPI:1245742907
Name:WILLEY, PATTI LYNN
Entity Type:Individual
Prefix:MRS
First Name:PATTI
Middle Name:LYNN
Last Name:WILLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATTI
Other - Middle Name:LYNN
Other - Last Name:ROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBOURNE
Mailing Address - State:WV
Mailing Address - Zip Code:26149-9687
Mailing Address - Country:US
Mailing Address - Phone:304-758-2611
Mailing Address - Fax:
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBOURNE
Practice Address - State:WV
Practice Address - Zip Code:26149-9687
Practice Address - Country:US
Practice Address - Phone:304-758-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV$$$$$$$$$Medicaid
WV$$$$$$$$$Medicaid