Provider Demographics
NPI:1891826848
Name:WILLETT, KRISTEN LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:LEIGH
Last Name:WILLETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1100 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6012
Mailing Address - Country:US
Mailing Address - Phone:770-886-8111
Mailing Address - Fax:770-205-8539
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 340
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6012
Practice Address - Country:US
Practice Address - Phone:770-886-8111
Practice Address - Fax:770-205-8539
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0549532081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA747640558CMedicaid
GA747640558BMedicaid
GA747640558AMedicaid
GA25BBGCJMedicare PIN