Provider Demographics
NPI:1760170757
Name:WILTZ, TIMEKA UVETTE
Entity Type:Individual
Prefix:
First Name:TIMEKA
Middle Name:UVETTE
Last Name:WILTZ
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 1:340 N SAM HOUSTON PKWY E STE A110T
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-3305
Mailing Address - Country:US
Mailing Address - Phone:346-917-3569
Mailing Address - Fax:
Practice Address - Street 1:340 N SAM HOUSTON PKWY E STE A110T
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-3305
Practice Address - Country:US
Practice Address - Phone:346-917-3569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01703193172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver