Provider Demographics
NPI:1386278505
Name:WILLETT WEBB, MARIAH (AGNP-C)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:WILLETT WEBB
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10136 NORTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DAWSON SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42408-8949
Mailing Address - Country:US
Mailing Address - Phone:270-619-3256
Mailing Address - Fax:
Practice Address - Street 1:10136 NORTONVILLE RD
Practice Address - Street 2:
Practice Address - City:DAWSON SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42408-8949
Practice Address - Country:US
Practice Address - Phone:270-619-3256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013156363LP2300X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology