Provider Demographics
NPI:1265985550
Name:WILLIS, SHAWN DALE (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DALE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 VICKERS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-9716
Mailing Address - Country:US
Mailing Address - Phone:304-855-1959
Mailing Address - Fax:
Practice Address - Street 1:67 VICKERS BRANCH RD
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508-9716
Practice Address - Country:US
Practice Address - Phone:304-855-1959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN66325-FNP-BC363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner