Basic Information
| Provider Information | |||||||||
| NPI: | 1376894840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 432 | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415020432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064302201 | ||||||||
| FaxNumber: | 2769350688 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SLATE CREEK RD SUITE 205 | ||||||||
| Address2: | |||||||||
| City: | GRUNDY | ||||||||
| State: | VIRGINIA | ||||||||
| PostalCode: | 24614 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 6064302201 | ||||||||
| FaxNumber: | 2769350688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007700 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100243540 | 05 | KY | MEDICAID |