Provider Demographics
NPI:1710153309
Name:WILLARD, C KAY
Entity Type:Individual
Prefix:
First Name:C
Middle Name:KAY
Last Name:WILLARD
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 1:3040 E QUEENS CT
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-0413
Mailing Address - Country:US
Mailing Address - Phone:352-637-1608
Mailing Address - Fax:352-637-1608
Practice Address - Street 1:3040 E QUEENS CT
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-0413
Practice Address - Country:US
Practice Address - Phone:352-637-1608
Practice Address - Fax:352-637-1608
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230012500Medicaid