Provider Demographics
NPI:1801289368
Name:WILLIAMS, MIRENDA LATISA (AGNP-C)
Entity type:Individual
Prefix:
First Name:MIRENDA
Middle Name:LATISA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 KARLBROOK LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-6199
Mailing Address - Country:US
Mailing Address - Phone:919-491-9226
Mailing Address - Fax:
Practice Address - Street 1:2365 SPRINGS RD NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3067
Practice Address - Country:US
Practice Address - Phone:828-325-0950
Practice Address - Fax:828-325-0248
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007484363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology