Provider Demographics
NPI:1215141429
Name:WILLIS, SHANNON RACHEL (RN)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:RACHEL
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6973 CHESTER DR APT A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1917
Mailing Address - Country:US
Mailing Address - Phone:608-279-1640
Mailing Address - Fax:
Practice Address - Street 1:6973 CHESTER DR APT A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1917
Practice Address - Country:US
Practice Address - Phone:608-279-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI150758163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse