Provider Demographics
NPI:1689159030
Name:TILLIS, SHAKARA
Entity Type:Individual
Prefix:
First Name:SHAKARA
Middle Name:
Last Name:TILLIS
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 1:4898 HIGHWAY 448
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:LA
Mailing Address - Zip Code:70441-3428
Mailing Address - Country:US
Mailing Address - Phone:225-571-7289
Mailing Address - Fax:
Practice Address - Street 1:4348 S JEFFREY DR STE 102
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-4196
Practice Address - Country:US
Practice Address - Phone:225-361-0219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator