Provider Demographics
NPI:1013336205
Name:WILLIS, KANDI LAUREN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KANDI
Middle Name:LAUREN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA
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 746216
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6216
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:58 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6017
Practice Address - Country:US
Practice Address - Phone:706-827-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant