MEDICARE: NICOLE LYNNE WILLIAMS PTA

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	225200000X	Physical Therapy Assistant	2074490	TX

General Provider Information

NPI Number	:	1649068834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LYNNE WILLIAMS PTA

Provider Business Mailing Address
First Line	:	415 SUFFOLK DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-2584
Country	:	US
Telephone Number	:	214-883-6712
Fax Number	:

Provider Business Practice Location Address
First Line	:	7929 BROOKRIVER DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75247-4900
Country	:	US
Telephone Number	:	214-389-6663
Fax Number	:	214-351-6453

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

Provider Enumeration Date	:	04/28/2025
Last Update Date	:	04/28/2025

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