Provider Demographics
NPI:1780261834
Name:WILLIS, SHANNA LYNN (CNM)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:LYNN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24455 PIPESTEM DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77355-6941
Mailing Address - Country:US
Mailing Address - Phone:832-768-1430
Mailing Address - Fax:
Practice Address - Street 1:419 GENTRY ST
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-8359
Practice Address - Country:US
Practice Address - Phone:281-296-0343
Practice Address - Fax:281-503-7765
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1033263367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife