Healthcare Provider Details

I. General information

NPI: 1619976792
Provider Name (Legal Business Name): SHAWNA C WILLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4724
  • Fax: 571-472-0241
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number14296
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number0101042052
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: