Provider Demographics
NPI:1285929620
Name:WILLIS, SHIRLEY VERNETHA III (REGISTERED NURSE)
Entity type:Individual
Prefix:MISS
First Name:SHIRLEY
Middle Name:VERNETHA
Last Name:WILLIS
Suffix:III
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:13136 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2423
Mailing Address - Country:US
Mailing Address - Phone:708-974-5800
Mailing Address - Fax:708-371-0466
Practice Address - Street 1:13136 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2423
Practice Address - Country:US
Practice Address - Phone:708-974-5800
Practice Address - Fax:708-371-0466
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-161525163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse