MEDICARE: SHAWNDAE NICOLE WILLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician	247200000X

General Provider Information

NPI Number	:	1073961272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWNDAE NICOLE WILLIS

Provider Business Mailing Address
First Line	:	9121 SAINT KITTS RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3523
Country	:	US
Telephone Number	:	817-907-3961
Fax Number	:

Provider Business Practice Location Address
First Line	:	9121 SAINT KITTS RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3523
Country	:	US
Telephone Number	:	817-907-3961
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	05/27/2016

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Directions to “ SHAWNDAE NICOLE WILLIS ” Practice Location

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