Provider Demographics
NPI:1003491283
Name:WILLIS, IKEYSHANA
Entity Type:Individual
Prefix:
First Name:IKEYSHANA
Middle Name:
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 1:17213 SUGARLOAF RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5209
Mailing Address - Country:US
Mailing Address - Phone:470-800-2040
Mailing Address - Fax:
Practice Address - Street 1:17213 SUGARLOAF RESERVE DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5209
Practice Address - Country:US
Practice Address - Phone:470-800-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service