Provider Demographics
NPI:1265054472
Name:WILLIAMS, TYTANARA
Entity type:Individual
Prefix:
First Name:TYTANARA
Middle Name:
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 1:569 COUNTY ROAD 3210
Mailing Address - Street 2:
Mailing Address - City:MT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-4125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:569 COUNTY ROAD 3210
Practice Address - Street 2:
Practice Address - City:MT ENTERPRISE
Practice Address - State:TX
Practice Address - Zip Code:75681-4125
Practice Address - Country:US
Practice Address - Phone:903-220-1871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352085164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse