Provider Demographics
NPI:1912541251
Name:WILLIS, KATHLEEN MICHELLE (COMMUNITY HEALTH WOR)
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:COMMUNITY HEALTH WOR
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 714
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-0714
Mailing Address - Country:US
Mailing Address - Phone:218-235-9539
Mailing Address - Fax:218-365-7843
Practice Address - Street 1:715 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1337
Practice Address - Country:US
Practice Address - Phone:218-235-9539
Practice Address - Fax:218-235-7843
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker