1588804751 NPI number — MRS. TANESHA MARNISE WILLIAMS

Table of content: MRS. TANESHA MARNISE WILLIAMS (NPI 1588804751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588804751 NPI number — MRS. TANESHA MARNISE WILLIAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
TANESHA
Provider Middle Name:
MARNISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDMOND
Provider Other First Name:
TANESHA
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588804751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6707 MAGOUN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMMOND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-554-0409
Provider Business Mailing Address Fax Number:
219-554-0409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5831 ERIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-853-0762
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 3747P1801X , with the licence number:  CNA0301514 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X , with the licence number: HHA0501037 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)