Provider Demographics
NPI:1336741982
Name:SHILULI, PHYLLIS SHANYISA
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:SHANYISA
Last Name:SHILULI
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 1:3100 SUGARBERRY LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-8567
Mailing Address - Country:US
Mailing Address - Phone:770-843-0504
Mailing Address - Fax:
Practice Address - Street 1:3100 SUGARBERRY LN
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-8567
Practice Address - Country:US
Practice Address - Phone:770-843-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF05180369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily