Provider Demographics
NPI:1679851067
Name:WILLIS, KENYA WASHINGTON (RPH)
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:WASHINGTON
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4112
Mailing Address - Country:US
Mailing Address - Phone:318-219-9554
Mailing Address - Fax:318-868-5373
Practice Address - Street 1:300 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4112
Practice Address - Country:US
Practice Address - Phone:318-219-9554
Practice Address - Fax:318-868-5373
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist