Healthcare Provider Details

I. General information

NPI: 1750154332
Provider Name (Legal Business Name): TYANNA MARIE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25701 N LAKELAND BLVD STE 403
EUCLID OH
44132-2453
US

IV. Provider business mailing address

1360 AVONDALE RD
SOUTH EUCLID OH
44121-2528
US

V. Phone/Fax

Practice location:
  • Phone: 216-273-7000
  • Fax:
Mailing address:
  • Phone: 216-856-5838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberSN664213
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: