Healthcare Provider Details

I. General information

NPI: 1114682788
Provider Name (Legal Business Name): TATIANA TESIA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/10/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3258 N 1ST ST
MILWAUKEE WI
53212-2061
US

IV. Provider business mailing address

4145 N 14TH ST
MILWAUKEE WI
53209-6906
US

V. Phone/Fax

Practice location:
  • Phone: 414-522-5692
  • Fax:
Mailing address:
  • Phone: 414-522-5692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberM2H5L6E2
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: