Provider Demographics
NPI:1124892708
Name:WILLIAMS, TANISHA S
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:S
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 1:812 SUMMIT GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-7733
Mailing Address - Country:US
Mailing Address - Phone:216-400-1043
Mailing Address - Fax:
Practice Address - Street 1:812 SUMMIT GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-7733
Practice Address - Country:US
Practice Address - Phone:216-400-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401442270912374U00000X
OH342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
No374U00000XNursing Service Related ProvidersHome Health Aide