Provider Demographics
NPI:1114709185
Name:WILLIS, SHINDELLA DENISE (CNCS,CBE,CD,CBC,CPD)
Entity Type:Individual
Prefix:
First Name:SHINDELLA
Middle Name:DENISE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CNCS,CBE,CD,CBC,CPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 BELLE GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-3724
Mailing Address - Country:US
Mailing Address - Phone:912-217-7561
Mailing Address - Fax:
Practice Address - Street 1:467 BELLE GROVE CIR
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3724
Practice Address - Country:US
Practice Address - Phone:912-217-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA253Z00000X
GA3941174N00000X
GA4457374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No253Z00000XAgenciesIn Home Supportive Care
No174N00000XOther Service ProvidersLactation Consultant, Non-RN