Provider Demographics
NPI:1679140743
Name:WILLIAMS, NICOLE SHUNTAY (LVN)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:SHUNTAY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 BROOKVIEW DR APT B
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-2370
Mailing Address - Country:US
Mailing Address - Phone:254-371-4858
Mailing Address - Fax:
Practice Address - Street 1:33003 BATTALION AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-618-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342246164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse