Provider Demographics
NPI:1982213088
Name:WILLIAMS, CHANEL TIARA (RN)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:TIARA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 GOVERNORS DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2948
Mailing Address - Country:US
Mailing Address - Phone:513-628-3212
Mailing Address - Fax:
Practice Address - Street 1:1102 GOVERNORS DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2948
Practice Address - Country:US
Practice Address - Phone:513-628-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH364065163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse