Provider Demographics
NPI:1073961272
Name:WILLIS, SHAWNDAE NICOLE
Entity Type:Individual
Prefix:
First Name:SHAWNDAE
Middle Name:NICOLE
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 1:9121 SAINT KITTS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-3523
Mailing Address - Country:US
Mailing Address - Phone:817-907-3961
Mailing Address - Fax:
Practice Address - Street 1:9121 SAINT KITTS RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-3523
Practice Address - Country:US
Practice Address - Phone:817-907-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other