MEDICARE: EDWANA DEATRICE WILLIAMS

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	251E00000X	Home Health Agency	2003674062101	NV
2	374U00000X	Home Health Aide	NV20171137651	NV

General Provider Information

NPI Number	:	1144759358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWANA DEATRICE WILLIAMS

Provider Business Mailing Address
First Line	:	3809 HAYWARD FIELD RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-1571
Country	:	US
Telephone Number	:	559-644-6150
Fax Number	:

Provider Business Practice Location Address
First Line	:	3809 HAYWARD FIELD RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-1571
Country	:	US
Telephone Number	:	559-644-6150
Fax Number	:

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

Provider Enumeration Date	:	06/09/2017
Last Update Date	:	07/21/2022

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