1295094753 NPI number — MRS. PHYLLIS MARIA WILLIAMS RN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295094753 NPI number — MRS. PHYLLIS MARIA WILLIAMS RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
PHYLLIS
Provider Middle Name:
MARIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1295094753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53 BEDFORD AVENUE
Provider Second Line Business Mailing Address:
TRUMAN J. MOON PRIMARY CENTER
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10940-6498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-326-1775
Provider Business Mailing Address Fax Number:
845-326-1789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53 BEDFORD AVENUE
Provider Second Line Business Practice Location Address:
TRUMAN J. MOON PRIMARY CENTER - NURSE'S OFFICE
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10940-6498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-326-1775
Provider Business Practice Location Address Fax Number:
845-326-1789
Provider Enumeration Date:
05/03/2012

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: 163WS0200X , with the licence number:  382068-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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