Provider Demographics
NPI:1295042042
Name:WILLIAMS, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
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 1:5775 WAYZATA BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1222
Mailing Address - Country:US
Mailing Address - Phone:763-291-1716
Mailing Address - Fax:
Practice Address - Street 1:6450 67TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-2468
Practice Address - Country:US
Practice Address - Phone:763-291-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN348032OtherCLASS A PROFESSIONAL HOME HEALTH CARE AGENCY