Provider Demographics
NPI:1114682788
Name:WILLIAMS, TATIANA TESIA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:TESIA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3258 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2061
Mailing Address - Country:US
Mailing Address - Phone:414-522-5692
Mailing Address - Fax:
Practice Address - Street 1:3258 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2061
Practice Address - Country:US
Practice Address - Phone:414-522-5692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIM2H5L6E2202K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology