Provider Demographics
NPI:1568966851
Name:WILLIS, SHARITY NICOLE
Entity Type:Individual
Prefix:
First Name:SHARITY
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 1:42 SMITH DR
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483-2901
Mailing Address - Country:US
Mailing Address - Phone:601-522-1264
Mailing Address - Fax:
Practice Address - Street 1:42 SMITH DR
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-2901
Practice Address - Country:US
Practice Address - Phone:601-522-1264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health