Provider Demographics
NPI:1124242011
Name:WILLETT, GAYLE (RN)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:WILLETT
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 1:8085 N EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-9212
Mailing Address - Country:US
Mailing Address - Phone:989-275-8385
Mailing Address - Fax:989-275-7009
Practice Address - Street 1:8085 N EVERETT RD
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-9212
Practice Address - Country:US
Practice Address - Phone:989-275-8385
Practice Address - Fax:989-275-7009
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704151085163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI47-04-151085Medicaid