Basic Information
Provider Information | |||||||||
NPI: | 1306827399 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | TERESA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NESSELROAD | ||||||||
OtherFirstName: | TERESA | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | DEPT. 453 PO BOX 1000 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8285752625 | ||||||||
FaxNumber: | 8283502174 | ||||||||
Practice Location | |||||||||
Address1: | 1828 PLAZA DR | ||||||||
Address2: |   | ||||||||
City: | WINCHESTER | ||||||||
State: | VA | ||||||||
PostalCode: | 226016365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5406629115 | ||||||||
FaxNumber: | 5406650411 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2005 | ||||||||
LastUpdateDate: | 04/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 0101267695 | VA | Y |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | VVW678F103 | 01 | VA | PTAN | OTHER | 1306827399 | 05 | VA |   | MEDICAID | 1306827399 | 05 | WV |   | MEDICAID |