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General NPI Number Information
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NPI Number | 1649964107
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Entity Type | Individual
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Provider Name | TISA MARIE WILLIAMS
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Gender | Female
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Dates
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Enumeration Date | 06/07/2023
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Last Update Date | 08/26/2025
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Provider Practice Location Address
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Address Line | 3999 DUTCHMANS LN STE 7B
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City | LOUISVILLE
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State | KY
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Zip | 40207-4742
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Country | US
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Telephone | 502-896-4791
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 776351
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City | CHICAGO
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State | IL
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Zip | 60677-6351
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Country | US
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Telephone | 502-559-9425
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Fax | 502-272-5339
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | APRN.CNP.0033951
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 4036265
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License Number State | KY
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