Provider Demographics
NPI:1780476093
Name:PETERS, WILLISHA M (RN)
Entity type:Individual
Prefix:
First Name:WILLISHA
Middle Name:M
Last Name:PETERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 N ROYAL ST STE B
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-2854
Mailing Address - Country:US
Mailing Address - Phone:985-241-5036
Mailing Address - Fax:
Practice Address - Street 1:1013 N ROYAL ST STE B
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-2854
Practice Address - Country:US
Practice Address - Phone:985-241-5036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 253Z00000X
LA240393163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care