MEDICARE: TYTANARA 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	164X00000X	Licensed Vocational Nurse	352085	TX

General Provider Information

NPI Number	:	1265054472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYTANARA WILLIAMS

Provider Business Mailing Address
First Line	:	569 COUNTY ROAD 3210
Second Line	:
City	:	MT ENTERPRISE
State	:	TX
Zip	:	75681-4125
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	569 COUNTY ROAD 3210
Second Line	:
City	:	MT ENTERPRISE
State	:	TX
Zip	:	75681-4125
Country	:	US
Telephone Number	:	903-220-1871
Fax Number	:

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

Provider Enumeration Date	:	05/11/2020
Last Update Date	:	05/11/2020

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