Provider Demographics
NPI:1750965695
Name:WILLIAMS, TINA (FNP-BC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:PITTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4110 W GUARD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-8048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4110 W GUARD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-8048
Practice Address - Country:US
Practice Address - Phone:208-272-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID68129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily