Provider Demographics
NPI:1801596754
Name:WILLINGHAM, SHANTELLE
Entity type:Individual
Prefix:
First Name:SHANTELLE
Middle Name:
Last Name:WILLINGHAM
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 1:122C NEW PROSPECT CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625
Mailing Address - Country:US
Mailing Address - Phone:864-276-7456
Mailing Address - Fax:
Practice Address - Street 1:122C NEW PROSPECT CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625
Practice Address - Country:US
Practice Address - Phone:864-276-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer