Provider Demographics
NPI:1699475483
Name:WILLIS, STASHA
Entity type:Individual
Prefix:
First Name:STASHA
Middle Name:
Last Name:WILLIS
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 1:1109 CARTER ST STE 3
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3227
Mailing Address - Country:US
Mailing Address - Phone:318-414-3065
Mailing Address - Fax:318-414-3067
Practice Address - Street 1:1109 CARTER ST STE 3
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3227
Practice Address - Country:US
Practice Address - Phone:318-414-3065
Practice Address - Fax:318-414-3067
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator