Basic Information
Provider Information | |||||||||
NPI: | 1356603864 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRISON WILLIAMS | ||||||||
FirstName: | MYECIA | ||||||||
MiddleName: | RA'SHAWNDA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARRISON | ||||||||
OtherFirstName: | MYECIA | ||||||||
OtherMiddleName: | RA'SHAWNDA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN, APN | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1259 WEST 112TH STREET | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082990530 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11200 LINCOLN HWY | ||||||||
Address2: | CVS/MINUTE CLINIC | ||||||||
City: | MOKENA | ||||||||
State: | IL | ||||||||
PostalCode: | 60448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154642171 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2012 | ||||||||
LastUpdateDate: | 06/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.009493 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.