Provider Demographics
NPI:1912353954
Name:WILLIAMS, LEATRICE SHAVONNE
Entity type:Individual
Prefix:
First Name:LEATRICE
Middle Name:SHAVONNE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEATRICE
Other - Middle Name:SHAVONNE
Other - Last Name:PINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3540 E BROAD ST STE 120-226
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5633
Mailing Address - Country:US
Mailing Address - Phone:972-460-6190
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5074
Practice Address - Country:US
Practice Address - Phone:855-984-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135810364SA2200X
LAAP07077364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health