Provider Demographics
NPI:1144759358
Name:WILLIAMS, EDWANA DEATRICE
Entity Type:Individual
Prefix:
First Name:EDWANA
Middle Name:DEATRICE
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 1:3809 HAYWARD FIELD RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-1571
Mailing Address - Country:US
Mailing Address - Phone:559-644-6150
Mailing Address - Fax:
Practice Address - Street 1:3809 HAYWARD FIELD RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-1571
Practice Address - Country:US
Practice Address - Phone:559-644-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2003674062101251E00000X
NVNV20171137651374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No251E00000XAgenciesHome Health