MEDICARE: DESHANA RACHELLE WILLIAMS CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency		OK
2	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1023612579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESHANA RACHELLE WILLIAMS CNA

Provider Business Mailing Address
First Line	:	4701 S 74TH EAST PL APT 2
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-6336
Country	:	US
Telephone Number	:	918-402-2832
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 S 74TH EAST PL APT 2
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-6336
Country	:	US
Telephone Number	:	918-402-2832
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2020
Last Update Date	:	11/25/2020

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