Healthcare Provider Details

I. General information

NPI: 1841998374
Provider Name (Legal Business Name): TINA IESHA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 05/04/2024
Certification Date: 05/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8416 TAFT ST
MERRILLVILLE IN
46410-6122
US

IV. Provider business mailing address

8416 TAFT ST
MERRILLVILLE IN
46410-6122
US

V. Phone/Fax

Practice location:
  • Phone: 219-750-9010
  • Fax:
Mailing address:
  • Phone: 708-310-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71013750A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number28222770A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberAG12220078
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: