Provider Demographics
NPI:1396307302
Name:KAYEMBE, WILLIE DITU (N/A)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:DITU
Last Name:KAYEMBE
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 ACORN GLEN TRL
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-2121
Mailing Address - Country:US
Mailing Address - Phone:832-714-9560
Mailing Address - Fax:
Practice Address - Street 1:1926 ACORN GLEN TRL
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-2121
Practice Address - Country:US
Practice Address - Phone:832-714-9560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171R00000X, 172V00000X, 343900000X, 344600000X, 347C00000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
No171R00000XOther Service ProvidersInterpreter
No172V00000XOther Service ProvidersCommunity Health Worker
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
No347C00000XTransportation ServicesPrivate Vehicle