Provider Demographics
NPI:1053118331
Name:WILLIS, KHCOLE
Entity type:Individual
Prefix:
First Name:KHCOLE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-1465
Mailing Address - Country:US
Mailing Address - Phone:402-708-0846
Mailing Address - Fax:
Practice Address - Street 1:4816 S 24TH ST # 14
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-2703
Practice Address - Country:US
Practice Address - Phone:402-320-5578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant