Provider Demographics
NPI:1518742709
Name:WILLIAMS, TEROSIA MOORE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TEROSIA
Middle Name:MOORE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7025 ETZEL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2458
Mailing Address - Country:US
Mailing Address - Phone:314-536-4661
Mailing Address - Fax:
Practice Address - Street 1:4624 LANSDOWNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-1523
Practice Address - Country:US
Practice Address - Phone:314-536-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023035135363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health