Individual
SHANIQUE TIARRA WILLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
110 SERIO BLVD, FERRIDAY, LA 71334-2013
(318) 757-8671
Mailing address
10 PINENEEDLE CT, SUMTER, SC 29150-8863
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
4356
SC
225200000X
Physical Therapy Assistant
Primary
CP025842A
LA
225200000X
Physical Therapy Assistant
PTA005056
GA
Other
Enumeration date
11/14/2023
Last updated
11/14/2023
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