Provider Demographics
NPI:1619698073
Name:WILLIAMS, TAMMY MICHELLE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MICHELLE
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 1:721 WAPPOO RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5861
Mailing Address - Country:US
Mailing Address - Phone:843-402-7850
Mailing Address - Fax:843-402-7851
Practice Address - Street 1:721 WAPPOO RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5861
Practice Address - Country:US
Practice Address - Phone:843-402-7850
Practice Address - Fax:843-402-7851
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28428164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1861678534Medicaid