Provider Demographics
NPI:1285249474
Name:WILLIS, KATHRYN SUE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SUE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 PERCENTUM RD APT 311
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-2141
Mailing Address - Country:US
Mailing Address - Phone:419-283-3260
Mailing Address - Fax:
Practice Address - Street 1:3316 PERCENTUM RD APT 311
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-2141
Practice Address - Country:US
Practice Address - Phone:419-283-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH48083283747A0650X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4808328OtherODM
OH013893Medicaid