Provider Demographics
NPI:1487852562
Name:WILLIS, KIMBERLY RACHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:RACHELLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:152 AVIARY CT
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-4054
Mailing Address - Country:US
Mailing Address - Phone:501-733-8722
Mailing Address - Fax:
Practice Address - Street 1:2609 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9428
Practice Address - Country:US
Practice Address - Phone:919-731-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01271207Q00000X, 208M00000X
ARE-5445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist