Provider Demographics
NPI:1437763950
Name:WILLIS, KAYLENE FAYE
Entity Type:Individual
Prefix:
First Name:KAYLENE
Middle Name:FAYE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 EBERT RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26710-8008
Mailing Address - Country:US
Mailing Address - Phone:304-813-3196
Mailing Address - Fax:
Practice Address - Street 1:161 EBERT RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WV
Practice Address - Zip Code:26710-8008
Practice Address - Country:US
Practice Address - Phone:304-813-3196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant