Provider Demographics
NPI:1154659100
Name:WILLIAMS, TINA DENISE (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:DENISE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161406
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38186-1406
Mailing Address - Country:US
Mailing Address - Phone:901-746-8078
Mailing Address - Fax:901-746-8943
Practice Address - Street 1:3385 AIRWAYS BLVD STE 304
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-3841
Practice Address - Country:US
Practice Address - Phone:901-746-8078
Practice Address - Fax:901-746-8943
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810532363LF0000X
TN146549363LF0000X
TN151209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022344Medicaid
TN1528450Medicaid