Provider Demographics
NPI:1437298742
Name:WILLIAMS, TERESA DIANE (APRN BC)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:DIANE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:MISS
Other - First Name:TERESA
Other - Middle Name:DIANE
Other - Last Name:HOLCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-7013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 WILLOWBROOK WAY SE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-1404
Practice Address - Country:US
Practice Address - Phone:706-625-6999
Practice Address - Fax:706-625-6990
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN107543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA428677375FMedicaid
GA428677375FMedicaid
GA202I505896Medicare PIN