Provider Demographics
NPI:1497441612
Name:WILLIS, TYNESHA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:TYNESHA
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 1:880 SOUTHERN AVE SE APT 102
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-3437
Mailing Address - Country:US
Mailing Address - Phone:202-981-0548
Mailing Address - Fax:
Practice Address - Street 1:880 SOUTHERN AVE SE APT 102
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3437
Practice Address - Country:US
Practice Address - Phone:202-981-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant