Healthcare Provider Details

I. General information

NPI: 1477287456
Provider Name (Legal Business Name): TANEISHA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 N PARK ST
EAST ORANGE NJ
07017-1734
US

IV. Provider business mailing address

163 N PARK ST
EAST ORANGE NJ
07017-1734
US

V. Phone/Fax

Practice location:
  • Phone: 908-644-4453
  • Fax:
Mailing address:
  • Phone: 908-644-4453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number123456
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: