Provider Demographics
NPI:1619579877
Name:WILLIS, SHALONDA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:SHALONDA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5434 CREEKSIDE RIDGE TRAIL
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449
Mailing Address - Country:US
Mailing Address - Phone:219-588-7387
Mailing Address - Fax:
Practice Address - Street 1:5434 CREEKSIDE RIDGE TRAIL
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449
Practice Address - Country:US
Practice Address - Phone:219-588-7387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX932095163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical