Provider Demographics
NPI:1790784254
Name:WILLIAMS-STUCKEY, TELINA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:TELINA
Middle Name:MARIE
Last Name:WILLIAMS-STUCKEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TELINA
Other - Middle Name:MARIE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:703-717-4149
Practice Address - Street 1:3918 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151
Practice Address - Country:US
Practice Address - Phone:703-657-6925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203850207Q00000X
VA0116024789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300389200Medicaid