Provider Demographics
NPI:1285045682
Name:WILLIAMS, TANISHA MONIQUE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:MONIQUE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP-C
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 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:910 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2414
Practice Address - Country:US
Practice Address - Phone:270-259-9555
Practice Address - Fax:270-259-1669
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008658363L00000X, 363LA2100X, 363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100453830-KOHMGMedicaid
KY201398760A (KOHMG)Medicaid
KYK212460 (KOHMG)Medicare PIN
KY7100453830-KOHMGMedicaid