Provider Demographics
NPI:1699365551
Name:WILLETT, KAYLA MONAE (SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MONAE
Last Name:WILLETT
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 E BUTLER AVE APT 406263
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-2513
Mailing Address - Country:US
Mailing Address - Phone:901-264-5363
Mailing Address - Fax:
Practice Address - Street 1:263 E BUTLER AVE APT 406263
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-2513
Practice Address - Country:US
Practice Address - Phone:901-264-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1916421744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN191642OtherSPECIALIST