Healthcare Provider Details

I. General information

NPI: 1730313040
Provider Name (Legal Business Name): GLORIA JEAN MCWILLIAMS MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6560 FLATWOODS BAY CT
LAS VEGAS NV
89122-3529
US

IV. Provider business mailing address

19230 YONKA ST
DETROIT MI
48234-1879
US

V. Phone/Fax

Practice location:
  • Phone: 313-408-1176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number225581
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: