Provider Demographics
NPI:1770854051
Name:WILLS, KATHIE JO (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHIE
Middle Name:JO
Last Name:WILLS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0746
Mailing Address - Country:US
Mailing Address - Phone:541-247-3300
Mailing Address - Fax:
Practice Address - Street 1:94235 MOORE ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444
Practice Address - Country:US
Practice Address - Phone:541-247-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000030721163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse