Provider Demographics
NPI:1629487186
Name:WILLIAMS, THERESA MILLER (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MILLER
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:FAIRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-838-8256
Mailing Address - Fax:
Practice Address - Street 1:142 SHERLOCK DRIVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1953
Practice Address - Country:US
Practice Address - Phone:704-838-8256
Practice Address - Fax:704-838-8251
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCM518AMedicare PIN