Healthcare Provider Details

I. General information

NPI: 1932389194
Provider Name (Legal Business Name): TINA JOANNE WILLIAMSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. TINA COPPLE

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 ELM ST SUITE 101
ALBANY OR
97321
US

IV. Provider business mailing address

PO BOX 1188
CORVALLIS OR
97339-1188
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-5820
  • Fax: 541-812-5821
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number200241926RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202111413NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: