1174793616 NPI number — MS. RONNIE DALE WILLIAMS CNA , CMT

Table of content: MS. RONNIE DALE WILLIAMS CNA , CMT (NPI 1174793616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174793616 NPI number — MS. RONNIE DALE WILLIAMS CNA , CMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
RONNIE
Provider Middle Name:
DALE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNA , CMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174793616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9415 THURMAN DR APT 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83714-1161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-302-0378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7683 W RIVERSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83714-6188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-853-2227
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MX060119 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00078560602 . This is a "IDAHONURSEAIDE PROGRAM" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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