Provider Demographics
NPI:1700496031
Name:WILLIS, KAYLA (AUD)
Entity type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5158 GA HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:IRON CITY
Mailing Address - State:GA
Mailing Address - Zip Code:39859-3304
Mailing Address - Country:US
Mailing Address - Phone:229-220-9936
Mailing Address - Fax:
Practice Address - Street 1:560 WESTGATE PKWY STE 4
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3076
Practice Address - Country:US
Practice Address - Phone:229-220-9936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1261A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist