Healthcare Provider Details

I. General information

NPI: 1760078414
Provider Name (Legal Business Name): WANDA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BROADWAY ST
PEARLAND TX
77581-4507
US

IV. Provider business mailing address

PO BOX 146
STAFFORD TX
77497-0146
US

V. Phone/Fax

Practice location:
  • Phone: 281-997-4400
  • Fax:
Mailing address:
  • Phone: 832-580-7432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number895816
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: