Provider Demographics
NPI:1992964332
Name:WILLIS, SHONDA L
Entity type:Individual
Prefix:
First Name:SHONDA
Middle Name:L
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 1:1012 BURKHARDT AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44301-1543
Mailing Address - Country:US
Mailing Address - Phone:330-724-2616
Mailing Address - Fax:
Practice Address - Street 1:1012 BURKHARDT AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44301-1543
Practice Address - Country:US
Practice Address - Phone:330-724-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2738345Medicaid