Provider Demographics
NPI:1992374508
Name:WILLIAMS, TERA KENYETTA
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:KENYETTA
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 1:10917 CLEARWATER DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-1599
Mailing Address - Country:US
Mailing Address - Phone:404-953-0882
Mailing Address - Fax:
Practice Address - Street 1:705 JUNIPER ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1307
Practice Address - Country:US
Practice Address - Phone:404-953-0982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0028886482376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide