Provider Demographics
NPI:1770479925
Name:WILLIS, ANGELICA SHEKIRRA (ADULT FAMILY HOME)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:SHEKIRRA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:ADULT FAMILY HOME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-1432
Mailing Address - Country:US
Mailing Address - Phone:920-461-6735
Mailing Address - Fax:
Practice Address - Street 1:1269 SMITH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-1432
Practice Address - Country:US
Practice Address - Phone:920-461-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant