Provider Demographics
NPI:1770228330
Name:TILLIS, SHONA MONIC (AGACNP)
Entity Type:Individual
Prefix:MS
First Name:SHONA
Middle Name:MONIC
Last Name:TILLIS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 W SUDAN CIR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7548
Mailing Address - Country:US
Mailing Address - Phone:662-822-2169
Mailing Address - Fax:
Practice Address - Street 1:1718 W SUDAN CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7548
Practice Address - Country:US
Practice Address - Phone:662-822-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905185363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care